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<br />INSTRUCTIONS FOR COMPLETING FORM "All
<br />GENERAL INSTRUCTIONS:
<br />SECTION 2711 oFriTLE. 23, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286, 25287, AND 25289 OF CHAPTER
<br />6.7, DIVISION 20, CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br />1. One FORM "A" shall be completed for all NEW PERMIT' CHANGES or any FACILrrY/SITEINrORMATIO'.\'CIIA.NIGES.
<br />2. SUBMIT' ONLY ONE (1) FORIM"A" for a Facility/Site, regardless of the number of tanks located at the site.
<br />3. This form should be completed by either the PERIMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br />4. Please type or print clearly all requested information.
<br />5. Use a hard point writing instrument, you are making 3 copies.
<br />6. Tank owner must submit a facility plot plan to the local. agency as part of the application showing the location of the USTs with respect to
<br />buildings and landmarks [Section 2711 (a)(8), CCRI. 1
<br />7, Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br />application for petroleum USTs [Section 2711 (a)(11), CCRI.
<br />TOP OF FORM: "MARK ONLY ONE ITEM"
<br />Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br />1. FACILITY/SITE INFORMATION & ADDRESS (MUST BE COMPLETE, D)
<br />1. Record name and address (physical location) of the underground tank(s).
<br />NOTE: Address MUST have a valid physical location including city, state, and zip code.
<br />P.O. BOX NUMBERS ARE NOT ACCEPTABLE.
<br />Include nearest cress street and name of the operator.
<br />2. Phone number must have an area code. If the night number is the same, write "SAME" in proper location.
<br />3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.).
<br />4. Check the appropriate box for TYPE OF BUSINESS.
<br />5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked -YES".
<br />6. Indicate the NUMBER of TANKS at this SITE.
<br />7. Record the E.P.A. ID # or write ".NONE" in the space provided.
<br />11. PROPERTY OWNER INFORMATION& ADDRESS (MUST BE COMPLETED)
<br />Complete all items in this Section, unless all items are the same as SECTION 1, If the same, write "SAME AS SITE" across this section. Be sum
<br />to check PROPERTY OWNERSHIP TYPE box.
<br />III. TANK OWNER IN[FORMATION & ADDRESS (MuSTBE COMPLETED)
<br />Complete all items ill this section, unless all items are the same as SECTION 1; if the same, write "SAME AS SITE"' across this section, Be sure
<br />to check TANK OWNI--'RSTYPl.,' box.
<br />IV. BOARD OI' EQUAI.JZAI-IONLIS'I'S'1'01tACrEFIFE ACCOUNT NUM13ER(MUST REC0,Mlll..EI'Ll),SEE AR-IICI..II5,CIIAIYI'FR6.75,
<br />DIVISION- 20, CALIFORNIA HEALTH AND SAFETY CODE.)
<br />Enter Your Board of Equalization (1301:) UST storage fee account number which is required before your permit application can be processed.
<br />Registration Nr ith the BOE will ensure that you will receive a qU3rlCrly Storage fee return in reporting the $00)6 (61nifls) per gallcm) fee dkw on the
<br />number of gallons PIUCCd in your USTs. Ila BOE. will code persons exempt from paying the storage fee So felurns wdj no! be SeJlt. If you do not
<br />have an account number with the BOE.' or if you have any, questions regarding the fee or excrilptions, picaso Call lhe BOF 'It 9 1 6 322-9609 or write
<br />to the 1401 --'at the following address Board of Equalization, Fuel Taxes Division, P.O. Box 9428719, S,.tcranwhto, CA 91,279-00A01,
<br />Ill: IROLFUM UST FLNANCIAL RI.`,Si,oNsiBiLrrY (MUST BE COMPLETED FOR PEIROLEUNI USTs ONLY, sl -"E SEC] IONS 2711 (4)(8)
<br />OFTITLE2.3, CHAPTER 16, CALIFORNIA CODE OF RLGIITLA-FlOiNTS.)
<br />Identify the nicthod(s) used by the owner andlor operator, in meeting the Federal and State financial responsibility rcquilu;n s;as. USTs by
<br />any Federal or State agency as well as non -petroleum USTs are exempt from this requirement,
<br />VI. I-I,'GAI,NO'lll-'ICA'1'10.NAND BILLING ADDRESS
<br />Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLIING \01 IFICATIONS.
<br />TANK OWNER OR AU'I'IIORIZI-.DRI-IIRESE.NTTAI'lVr- MUST SIGN AND DATET111", FORM AS INDICAI'H). ISFFSEC]IONS T'll
<br />(a)(13) OFTITLE, 23 Cl IAIII*I:R 16, CALIFOKNIA CODE OF REGULATION'S.]
<br />INSIRUC-110-N FOR THE LOCAL AGENCIES
<br />The county an jurisdiction numbers are Predetermined and call be obtained by calling the Stato, Board toll(i) 227-4303, "Ile facility ntiTiit)crmrayt)(,
<br />assigned by the local agency; however, ever, this number must be numerical and cannot contain any alphabetical characters. If the local agency pretcrs
<br />the State Board to assign the facility number, please leave it blank.
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<br />IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILYI'Y TO VERIFY THE ACCURACY OFTHE
<br />INFORMATION. TIIIS APPLICATION CANNOT BE PROCESSED IF THE BOF ACCOUNT NUNIBER 1SNOT FILLED IN. THE LOCAL
<br />AGENCY IS RESPONSIBLE FOR THE C01',41ILLTION OF THE "LOCAL AGENCY USE ONLY` INFORMATION BOX AND FOR
<br />FORWARIXNG ONE. FORM "A" AND ASSOCIATED FORM "B"(s) TO THF. FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br />RETAIN'] HE'. ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br />RETAINED 13Y THE' TANK OWNER.
<br />STATE OF CALIFORNIA
<br />STATE WATER RESOURCES CONTROL BOARD
<br />C/O S.W.E.E.P.S.
<br />DATA PROCESSING CENTER
<br />P.O. BOX 527
<br />PARAMOUNT, CA 00723
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