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INSTRUCTIONS FOR COMPLETING FORM "A",
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER l6,CALIFCIRNIA CODE OF REGULATIONS AND SECTION';25286 X5297,AND�5289 OF CHAPTER
<br /> 6.7,DIVISION 20,CAL117ORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS'T TO APPLY FOR AN UST°OPETirs'TlN(3 PERMIT
<br /> 1, One FOR "A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES,
<br /> 1 SUBMIT ONLY OOT (I)FORM"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 PERMIT APPLI ANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR,
<br /> 4. Please type or print clearly all roc;nested information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies,
<br /> 6. Tank owner r gust submit a facility plot plan to the local agencyLs part of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(S),CCR].
<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)(t 1),CCR].
<br /> TUI'OF FORNt"MARit ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item haat best describes the reason the forret is being completed,
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<br /> T. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> I. Record name and address(physical location)of the underground tanks),
<br /> NOTE: Address MUST have a valid physical location Lneluding city.supe,and zip code.
<br /> P,O) BOX NUMBERS ARE NOT ACCEPTABLE,
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number mast have ars arca code,. If the fright number is the same,ww to"SA NIE'"in f I xr'l�at"ron.
<br /> 3. Check the appropriate bort lot TYPE OF BUSTilI S'OWNE' SITIP(Tr O 'OR 3 10`11 INI,8VlDUAF,ctc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS,
<br /> 5. If Facilit;'f site is located within an Indian,reservation or other Indian trust lands,check the,box.narked"YES",
<br /> 6. Indicate the NUN4BER of TANKS at this SITE.
<br /> 7_ Record the E,R A.11)g or write"NONE"in the spaacr.,provided.
<br /> lit PROPERTY OWNER INTt?I?MATION&ADDRESS(MUST lei„COMPLETED)
<br /> Complete all items in this section,unlessan iters",are th sat ne is SECTION I I3 i,.> : e,write"S.AyIE AS SITE"acrwo4 this';c fl n. Be seise
<br /> to check PROPERTY OWNERSHIP TYPE box,
<br /> III.TANK OWNER INFORMATION&ADDRESS([st UST E COMPLETED)
<br /> Complete all:i€encs in this,sections„unless aall items are the sand as SECT1OaN i s if the sam ,write"SAME AS SITE"across this seviom Be sure
<br /> to check TANK OWNERS TYLE box.
<br /> LV,BOARD OF EQUA LIZATION UIST STORAGE FEE ACCOUNT NUMBER(%4UST LIE CONTPLET'l IF.SET:ARTICLE 5,CHAPTER 6,7 5,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFE—1 a'CODEJ
<br /> Enter your Board of Equalization(BETE)UST storage fee account number which is requirod before your pernik application can be processed,
<br /> Registration with the POE will ensure that you will receive as quarterly storage fee ray umn,in reporting 1 e per gadion fee due on the member of
<br /> gallons placed in your UST,. The EOE will erode persons exempt from Paying the snrogt fee so returns will not t be sena: Ifyou do not have an
<br /> account ntaaxabor with the'EOE or if you haveany ny questions restart'n>the fee tar extanloions,,,is a�earl the BOE at 916-12` 9669 or write to the
<br /> ROTE at the following;add e.ss Bowd of Edualiz tion,Fuel Taxe.,Divi cm,RO.Box 9-11819,Sacramento,CA 9,2:t(Jt 1 L
<br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY tI II.ISTBE C C?1sIF'L TS)F't%T'I I'?S.l"ROLE'UM USTs ONLY,SEES CTIO S 2711 (a)(11)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,)
<br /> Identify the Method(s)used by the owner aadlor operator,in meeting the Federal and Stain,financial responsibility requiretnerns,LSTs owned by
<br /> any Federal or Slate agency as well as non-petroleum USTsare exempt from this req airern nt.
<br /> VI,LEGAL NOTIFICATION ANIS BILLING ADDRESS
<br /> Che=ck ONE,BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK OWNER OR AUTHORIZE[')E[')REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATE,), [SEE SECTIONS 2711
<br /> (a)(1.3)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,]
<br /> INSTRUCTION FORTHE LOCAL AGENCIES
<br /> The county and]urisdic€ion numbers are predetermined and can be obtained by catling the State Board(916)227-4301. The facility number may
<br /> be assigned by the local agency;however,this number crust in m"nerical and(cannot contain any alphabetical characters, If the level agency
<br /> prefers the`tate Board ccs assign€hc facility number,please leave it bka€ak.
<br /> IT IS THE RESPONSIBILITY OF `tT1E LOCAL AGENCY THAT !NSPE 15 THE i A„'IIJT3 TO VERIFY LTL ACa:tAkACY OF THE,
<br /> INFORMATION, T141S APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL
<br /> AOENC;°Y IS RESPONSIBLE FOR TFfE COMPLETION OF THE,"LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL
<br /> AGENCY SHOULD RETAIN 'T°LITii )RIGINAL... AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
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