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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OFTITLE 23;CIIAPTER I6,CALIFORNIA CODE OF REGEILATIONSAND SECTIONS M86,25287,AND 25289 OF CHAPTER
<br /> 6.7,.DIVISIO Sr 20,CALIFOR-NIA HEALTH AND SAFETY CODE REQUIRE,OWNERS TO APPLY FOR AN UST OPERATUN PER.
<br /> 1. One FORM"A"shall be completed fol-all IaEW TPERINIF!'C<<a:NG S yr any FAC CLI YISITE INFORMATION CHANGES,
<br /> 2, SUBMIT ONLY ONE(1)FORM"A"for a Facility/She,regardless of the n€mber,of tanks located at the site.
<br /> 3. This form should be completed by either the Pl-,R,-IIT APPLICANT or the LOCAL AGENCY UNDL11GROUNT)TANK INSPEC"1 OR,
<br /> 4. Please type or print clearly all requested information.
<br /> S. Use a hard point-N�riturg instrument,you 11are making 3 copies.
<br /> 6. "Lank owner must submit d facility plot plan to the local agency as Hart of the application showing the location of the Una with respect to
<br /> buildings and landmarks f Secti n 27,11 I(a)(S),CL RJ,
<br /> T Tank owner must submit atncurncnta£ion showing compliance with state financial responsibility i�qsai re,r �to theloc.ala encv as rt of the
<br /> application forp:trolcuin UST's[Section'271 t(a)(1 t),CCR,
<br /> TOP OF FORM:"MARK ONLY ON Ii I t'ENl" ;
<br /> Mark an(X)in the box next to the.item that best describes the reason the fforra is being completed.
<br /> I. FACILITY/SUFE I:;l'ORNIA'TION&ADDRESS(MUS T BE COMPLETED)
<br /> 1. Record name and address(Physical log atiort)of the undcrgrotuid tank(s),
<br /> 'IlOTE;Aiddres's NliUST,have a valid physwaa location including city,state,and zip,code.
<br /> ,P.O.Bfy yNU BERS ARl',NOI'ACCE IABLE<
<br /> Include,nearest cross s cut and narne;oaf 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 d e apl>c6priatc box fcir"3 YPIT CtT`I v`INE SS C3W NIiRSIiTP{ex,CORPORATION I LN' I IDUAL,etc.)
<br /> 4. Chock ilie appropriate box for TYPI OF BUSINESS,
<br /> S. If Fac ilitytliiw 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 /> T Record the E.P.A.ID#scar write"NONE"in tine space Provided.
<br /> H.'PROPERTY OWNER INFt3RMATION&fiD?}FII:S`s(MUS-i"Br C:CT,M PLLTFD)
<br /> CoFnplete all items in this s€xclion,urdc ic;sit ucins are the same as SEC"11ON 1,It the sarin,write"SAMI^:AS SfIT"aeries,this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE t c x.
<br /> III'.'IANR.OWNER INFORiAT�ION&ADDRESS(NUS BECONIPLEIT.D)
<br /> e
<br /> Cornfilcto all ite nts in this section,€mess all tuns are the s.arne as aSEC"IO I;1.f lite same,write"SAME AS Sl7l E across t';ais seutitma, lie,stare
<br /> '..to oJieck TANK OWN NLRS FIT.box.
<br /> IVBOARD C?:;t:QU el_ZA I iO 3.S r S i O 'GE 1 FE ACCOUNT NUMBER(MUS BI:.COMPLETED.SEI ARIFICLI,5,CII AI-I I,,R 6,75',
<br /> DIVISION 20,CALIFONIA1iFALT:IANDSAFEiYCODE.)
<br /> I nti r your Boal d of t qua.ira ion(130,E)U S I'&toragc fee account number%vhi h is required before your pc inlet a Ypfiyz ai,n C:in be pros-. cd,
<br /> 1Z+.S„tzat.i>ri t3 ah 1h t7.,t ,xa will receive a Stalrterly stotaage fee return in re}aorting the;;fi 0)6(Sit a'..;}per r _k,`A,f,ta *'eau ort the
<br /> not ober of„a..,>sa Tit acute tat <err _3r1's. °111e ISCif,will csr c:1x rstiias cxcrri}zc from baying the st<>taLe fee stip a rra�r. �t3 a.i ho"'lo- Cl vcPas ”:,i sit
<br /> hale an icc.outg nurnli i'w;,,a i'r 1101E or if yo-,u h.av„art'questions regaeding the fee or exe,laptitnt..,pleasi,call ihe ll(Al ail 91 5 2"U-%(i)or.;rite
<br /> to the 130h at the fE.h»irrg addr-"Bod of Egaaaliaatiorn,ForelTaxes Divi ion,P.O:"B6ts 942879,Sr»: , ,"ionto,CA
<br /> V, 1'E'I'?tC)L''U S r, `I\.:\C,:<i,IZi..7r'C i3lt l`t"Y(SIU "3 z31i C'(3 aI'1,I"t'a i3 Tr£1zZ tPi'I ICC)I.il;[tT t i` C} i,U„4i,1?.tC.C:11C3 't l t a(' i
<br /> 3de a„iE:y the c.,:,K#(,j eas;,u by,hua r and,
<br /> Wor operator,In niceling the Federal and State fin anoial rr,pn�i,.a,.ty rc .a, .,.;d,fa .t.S 's
<br /> any Fc,d crid err Statc s ri t°as a ell as non g-retrol uno USTS arc exempt from this requiren,t"rit.-
<br /> VI.LEGAI,NOT;,KATION AND B1111NG ADDRESS
<br /> Check ONII BOX for th::ad lass tha?x dl b; tried for BOTH L EG;AI.AND BILLING N(3'1'IVICA i'1t?NS:
<br /> TANls OWNER ORi l l?f?.Ti<!isD RLI'RE.St'N-l7A IVF MUST S.JGN AND 33A'I`I: 1}Ili F£?1;M AS INDICA IISI.f
<br /> (a)(13)0,11 1 ITLE,2, CIIAP' FR 16,CALIFOR'NIA CALIFORNIACODE OF REIGU'L,ATIONS.I`
<br /> INSIRUC11ON FORTH!-,LOCAL,YGENCIEUS
<br /> The county an jaarisdiction niimb rs are I,tc detcunnied and can be obtained by calling the State Board{�16)227-4301 ,,.0 a.,y umber may h
<br /> assigned by the lcxal at, lacy,hu%vevcr,this ituniber niust be numerical anti cannot contain any alphabetical charac.tcrs, If the lova.age;ney peeicrs
<br /> the State Board ut a.s gn the facility number,please leave it,blank.
<br /> IT'IS THE'' RESPONSIBILITY 01FTHE LOCAL AGENCY”TETAT INSPECTS '11IE FACILITY_TO VERIFY THEACCURACY OF'17113,
<br /> INFOR A'1`ON. THIS APPLICATION CANNOT BE PROCESSED II:THE BOE ACCOUNT NUMBER IS NOTFILLED IN, TTTE I-CAL
<br /> AGENCY IS R Sl ONSIB11,E FOR THF CO"A PI.ET1ON OF THE "LOC"AL AGENCY USE ONLY' INFORMATION BON AND FOR
<br /> FORWARDING ONE'FOICN1 b"AND ASSOCIATED FOR "B"(s)TO THE FOLLOWING ADDRESS, THE LOCAL AGI-NCY SHOULD
<br /> _.RETAIN I HE ORIGINALS AND FORWARD THE;YELLOW COPIES`ET1 THE FOLLOWING ADDRESS.THE PINK COPY SHOULD FIB
<br /> RETAINED BY'TI3E TANK OWNER.
<br /> S'T'ATE OF CALIFORNIA
<br /> STA'I'R WATER RESOURCES C(7�C'TROL BOARD
<br /> C/O S W,E,ll T'S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3'93FOR012DR1
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