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INSTRUCTION FOR COMPLETING "A"
<br /> GENERAL INSTRUCTIONS:
<br /> , CTION 2713 ObTITLE 23,CHAPTER 16,CAL,Ih0IUNTIA CODE OF REGULATIONS S AND SKC:TIONS 25246,25287,ND 25289 OF CHAPTER `
<br /> 6.7,DIVISION 20,C"ALIItORNIA HEALTH AN L7 SAFETY CODE RLQUIRE OWN, TO APPLY FOR AN UST OPERATING PEP-NIIT.
<br /> f. One FORM"A"shall be completed for all NEW PERIEiT ClIAF:CES or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2. SUBIMIT ONLY ONE(1)FORNI"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This for should be c nnplcted by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR
<br /> 4. Please type or print clearly all requested information.
<br /> 5,. Use a hard point wriiin€3 instrument.,you are making 3 copies.
<br /> 6. Tank owner most submit a facility plat plan to the local agency las parr of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2731(a)(8),C RI.
<br /> 7. 'Panic owner utast.submit documentation showing compo anb e sarin.state financial responsibility requirements to the local agency as Tram cif the .
<br /> application for petrtilc urn USTs[Section 2712-(a)(11),C Isj,
<br /> TOP OF FORM:"MARK ONLY ONE,ITEM"
<br /> "Hark an(X)in the box next to the item'that best describes the reason the form is ging coxnplroe:1
<br /> I. FACILITY/SITE INFORMA'IIC31K&ADDRESS(NIUST BE COMPLETED)
<br /> 2. Record name and address(Physical laxation)of the underground trink(s).
<br /> NOTE:Address MUST have a valid physicist location including city,state,,and zip code.
<br /> R0,BOX NUMBERS ARE NO ACC:EI''iABI- .
<br /> Include nearest crass"strecs and ria€ne of the operator;
<br /> 2. Phone number must have an"arca sodei if the night number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate lox forTYPE OF BUSINESS OWNERSHIP(ex,CORPORATION,N, DIVIDUAZ,etc.).
<br /> 4. Check the appropriate;box for TYPE OF'13US-INESS.
<br /> 5. If}acility,Site is located within an Indian reservation or otherIndian,trust lands,check the,box marked'"1 YE.S".
<br /> Ca< Indicate the NUMBER cif TANKS at this SITE,
<br /> 7. Record the.E,P,A.II)#1 or write 'NOINE"in the space pawided.
<br /> TI. 'PROPS"I TY C3VvNFR RNFtIIUMA11ON?&ADDRESS(MUST BE CPf.ia1 ED)
<br /> Complete all thorns in this section,unde.ss all items are the sante as SECTION 1,If the rarer ,varit�''S A ,k„AS SITE"across this soctic Be sure
<br /> to check PROPERTY OWNI:IRSIIIP TYPE,bcx_
<br /> LII.TANK OWNER INFORNIATION&ADDRESS(MUST131.,1'COINI I-LIED)
<br /> Complete all nears in this rection:,unless all items are the sante as SECTION 1;If Che;sarr e,write SAME AS SFITI a ros. t1,ts scnicnt. Be sure
<br /> to check'FA'4K OWNI'RS T 1Th box:. -
<br /> IV.BOARD 0I,'1,QUAI.JZA°I l0N UST STORA E IrlIE ACCOUNT"otsT1131R(MUST 1311,%.«v 11'L E TLII.SEI.ARTIC:'L,1; ,C°11.fIThR 6,is
<br /> DlV?SION 20,C.1NF IRNIA HEALTH AND SAFETY CODE.) _
<br /> I'm Ta,your 13;,a.x:of ci z sazaiion(13(:)al)UST storage,fec account nit (rcr whiti?a is,equiled lx.fore your gxa .nt a ph,,id: ,Can be pwcess£xL
<br /> Registr ativn� ith tht�130E wil,enswe 0 at you u;lt receives gvanerly s€orage fee rr_�tar€mn repkiiiwg s'.ac Sucyoo(on"J 1 per due sari the
<br /> ntarca(=cr<>t g<t i;?ns pl.;G.e 'ata po r L:S.s. "lhc B i�w l cot c l °rso s uacn.ptfrczts pa Cir,r„,lxc stcx a,,c i.e at c ;a,Es; ,<t sii3 ;:, .art. to sin,o not
<br /> have,an accts.,,t fr,zm wr'wi b the BOL or if you have any qucsvoni regarding,the.ce or z.,.r;nsti.,ttt,,, i_as, a.l tho f>t,l.,ts 316 322-<t;a)o ,nio
<br /> to tho 11301.at the(cal,uwinal addrsss Board of Equstizatn,iu,l'uel'Iaxes Division,P.0,.Box 9,128-79,;,.<,t.<t;t,.,.,c§,CA 94279-0(;;)I,
<br /> Y. t'l: 2CC}l
<br /> C)I'"1'1 I''ss 23,(ll A1'�1`1:aC l,ta,CALsI't)I3\ht CC?L)E C3E�IC l.:C3hls1'1'la)1`ti.}
<br /> Id t tify the rstctt.cxl(s)wscd b,,the owner and Or operator,it,€ne'!'Zing tate Fccdcrral data St„,c iaa<rnct.a,.cspor. ,.tx,l ,, a.r .,.:.;t i .H`i's; ..0 b
<br /> any Ic.:coal oa'St:€tc agcrrt y as well as noel-petrot.,utrt LS'Ia are exempt Trona tt;s r,.qa:rn..r<er;t.
<br /> VI.11it1AL:01,11?aCA'110N AND BILLING ADDRESS
<br /> Check ONE 13OX for th, adieu that will be used for BOTH L,TIGAL AND BILIANG N0l',''C£. e 10 S,
<br /> 'TANK C:}yG NEIR(;)R At,I'HORI:Il 1:I R P ESL 1'ATIVE Ml;ST S1G AN,[)t:)d's'ITE`1 HE AS I=+I)!t.,Mi le,. ;t.., .`.,..C,;l �:S 2'/11
<br /> (a)(I3)OF 1I LE'23 C1IA 11t 1l,16,CALIFORNIA CODE OFiZ Cah A'l]0NS.j
<br /> R&IRUCI`ON FOR I III'L )C;AL.AC;I NC::IES
<br /> The counry an jurisdiction numbers are predetertnined and can be obtained by calling the S a.A Isar.Fri(S'16)227 4303. 1 he faciloy tit,arah:r rn av lac;
<br /> assigned by the local agency;however,this numb.rrrtust be numerical and cannot :coram,any characters. If'thv local a en y prc tdrs
<br /> the State Board to assign the facility number,please leave it blank:
<br /> IT IS TIl";l RESPONSIBILITY OFTHE LOCAL AGENCY THAT INSPECTS THE FACILITY
<br /> TO 4'L°I<IFY 'I`(Ik1, ACCURACY OF'111E
<br /> E\'FORMA[`ION, "l'IitS API'i.ICATIO CA°iN'OT BE,PRO ESSFD II'°I`IIE BOE ACCOUNT°st: SC3tIIZ IS NO'1"It11.1 LD IN, 'L`HE LO AL
<br /> AGENCY 1S Rl,"SI'{.N"MiLE IFOR Tl1E COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORIIA"TION BOX AND FOR
<br /> FORWARDENG ONE I'LvaldM"A`AND ASSOCIATED FORM"B"(s)I'D THE FOLLOWLNG ADDRESS, THE LOCAL AGENCY SHOULD
<br /> RETAIN'Tilt,'ORIGINAI S AND FORWARD THE YELLOW C OPI£S,TO THE FOLLOWENG ADDkESS.THE PINI{C6PY SHOULD BE
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C./O S 4Y.F,E,P.S.
<br /> DATA PROCESSING CENTER
<br /> P,O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 193 FOR012DRI
<br />
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