|
0
<br /> N "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 2i286.25287,AND 25`89 OF CHAPTER
<br /> a
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN EST OPERATING PERMIT,
<br /> 1. One FORM"A"shall be completed For all NEW PERMIT CHANCES or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2, SUBMIT ONLY ONE(1)FORM"A"for aFacility/Site,regardless of the number of tanks located at the site.
<br /> 3. This form should be completed 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 writing instrument,you are snaking 3 copies.
<br /> 6. Tank owner must subant a facility plot plain to theJocal-agency as part of the application showing the location of tine UST's with respect to
<br /> buildings and landmarks(Section 2711(a)(6),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 2721(a)(11),CCRJ.
<br /> TOP OF FORM "MARK ONLY ONE ITEM"
<br /> Mark.an(X)in the box next to the iters that best describes the reason the form is being completed.
<br /> L FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<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,mad zip code,
<br /> P,O.BOX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code.. If the might number is the same,write."SAME"in proper r locati an.
<br /> 3, Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,em,).
<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 lah&,check the box marked"YES". d_
<br /> 6. Indicate the 'UMBER of TANKS at this SITE.
<br /> 7. Record the E,P,A.ID p 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];If the sarrtc,write "SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> 111.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETER)
<br /> Complete all items in this section,unless all items are the saarne as SECTION 1;If the same,write"SANTE AS SITE"across thissection, Be sure.
<br /> to check TANF4 OWNERS TYPE box.`
<br /> IV,BOARD OF EQUALIZATION UST"STORAGE FEE ACCOUNT NUMBER(MUSTBE COMPLEFED.SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH ANIS SAFETY CODE,)
<br /> Enter your Board of Equalization(BOE)UST storage feeaccount number which is required before your permit application can bw processed.
<br /> Regisiration with the BOB will ensure that yon will receive a quarterly storage fee return in reporting the per gallon foe due on the number of
<br /> gallons placed in your USTs, The 96E wilf code persons cxempt from paying the storage fee so returns will not be sent. If you do not have an
<br /> account number with the BOE or if you have any questions regarding the fee or exemptions,please call the BOf at 916-322-9669 or write to the
<br /> BOB at the following address hoard of Equalization,Fuel Taxes Division,P,O,Box 942879,Sacramento,CA 94279-0001,
<br /> V. PETROLEUM LIST FINANCIAL RESPONSIBILITY"(MUST BE COMPLETED FOR PETROLEUM UST's ONLY,SEE SECTIONS 2711 (a)(I1)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the methods)used by the owner and/or operator,In meeting the Federal and State financial responsibility requirements,USTs owned by
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement,
<br /> VI.LEGAL NOTIFICATION ANIS BILLING ADDRESS
<br /> Check ONE BOA for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK OWLET/OR AUTHOR17—FD REPRESENTATIVE MUST SIGN AND DATE THE.FORM AS INDICATED, (SEE SECTIONS 2711
<br /> (a)(I3)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,]
<br /> INSTRUCTION FOR TIME LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303, The facility number may
<br /> be assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters: If the local agency
<br /> prefers the State Board to assign the facility number.please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE, .,..w
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOB ACCOUNT NUMBER IS I"OT rILL8D IN. THE L(3 A[
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOC T_AGENCY USE ONLY" INFORMATION`BOX. THE LOCAL
<br /> AGENCY SHOULD kETAIN THE kimAA AND YELLOW C3PIE .' THE PINK COPY SHOULD BE RETAINED BY THE TANK-
<br /> OWNER.
<br /> m
<br /> 6,195
<br />
|