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<br /> INSTRUCTIONS FM COt.MPLETING M'"Att
<br /> CiENFRAL INSTRUC''T`ONS: „
<br /> S13=0N 271 LOF TLT'LS.23X9 AFTER 16,CALIFORNIA CODE OF RIr ULATIO'� AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 63;,DIVPION 20,CALLFORNIA'HEALTH AND SAI'ETY CODE REQUIRE OWNERS TO APPLY FOR AN US;r QP,ERATING;PI„12MIT.
<br /> t' 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FAC UATY/SITE INFORMATION CHANGES.
<br /> 2 SIlRTAIT ONLY ONIi(13 FORM"A"for a Facility/Site,regardless of'ihcnuinbei of tanks Iocatcd at the site,
<br /> 3. This form should be completed by either the PERMIT APPL ICANT'or ifeLOCAL AGENCY UNDERGROUND TANK TNSPECTOk
<br /> > zt, 4:`Please iype or print clearly all requested information.
<br /> S. Use a hard point writing instrument,you are making 3 copies.
<br /> ° s 6.Tank owner must submit a facility plot plan to the local agency as partofthe application showing the location of the USTs with inspect to
<br /> buildings and landmarks[Section 2711(a)(8),CCR).
<br /> T Tank owner must submit documentation showing compliance with Mite financial responsibility vegnif0_rents to the local agency as part of the
<br /> appliawon,for petroleum USTs(Section 2711(a)(I 1),CCRj
<br /> ' TOP OF FORM:"MARK ONLY ONE ITEM _.
<br /> t**- Madru&M in theibw next to_the item that best describes the reason the-form is being comply
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<br /> 1rr ,1z7RCILITY/51TE INFOIZI-lA'I ON&ADD DSS(MUST BE;COMPLETED)
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<br /> 1. Rdsovd.uame''and address(physical location)of the underground tank(s).
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<br /> NOTE: Address MUST have a valid physical location including city,state,and zip code.
<br /> P.O. X NU 4tB}'RS ARL NOT ACCEPTABLE.
<br /> In_cltidl:nearest cioss street turd name of the operator. , f*
<br /> _•,- 2. Phone nuii must have att,area code. If the night number is,the some,write"SAME."in proper location.
<br /> f' 3. Check tha appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL.,etc.). „
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> FacilTty/St.Gg is,located within an Indian reservation or other Indian trust landilx,check the box marked."YES".
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Relcord the E.P.A M 0 or-w4te"NONE"in the space provided. AA
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<br /> i II. PROPERTY OWNER'WFORMATIUN&ADDRESS(MUST BE COMPLETE
<br /> Complete all items in.his section,unless all items are the same as SECTION 1,N the same.write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> h TA_I K.OWNER INFORNtATION&c ADDRESS(MUST BE COMPLETED) y
<br /> r+ Complete all items'ln iMs section,unless all items are the same as SEC"TION�1;_If thio same,write"SAME AS SITE"across this section. Be sure
<br />[% to check TANK OWNS TYPE box.
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<br /> ry AV:BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST•-BBCOM"TED.SEE"AgTICI F 5,CHAPTER 6.75,
<br /> ` DIVISION 20,CALIFORNIA IIEALI11 AND SAFE-Cy CODE,.) � ; 5 a..•,. "' < ?
<br /> y. Enter your Board of Equalization(BOE)USTstorage fee accotmt rs bertrh'ieB sed befz your permit application can be.processed.
<br /> Registration with the BOE will ensure that you will receive a quarterly storage fee ret*iii-reponing the SO.006(6mitls)per gallwt fee due on the
<br /> numbsxtzfgallsiu�plascs in yourUSTs. 7hc BOE will code pea orulexempsfrompaying the storage fee so returns will not be sant. If you doncrt
<br /> havc.an account-buo tcr'vith the BOG or if you have anyquestidns regarding thtrfm�. 'tatcrnptions,piease call the BOE,at z)161322.9669 or barite
<br /> to the:BOE at tate tov 4)&address Board of Equalization,Fuel Taxes Divisitinl P.O,Box 942879,Sacrairunto,Cal 9127•)-0001.
<br /> ' V. PETItOI..um L'S"1'FL\A;tiCl,1i,RESPO\S113II.I'I'Y(MUST BE COViPLETEDFOR PETRO USTs ONLY,SLI: iiCllONS 271 i {a)(fi'
<br /> OF IITJ.Li.23,.CIi lI'TL•It.l--f,CALIFORNIA COI)E OF RLGULATIOi<IS). -.. .
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<br /> Identify the mcthcxl(s)ysnd by the owner and/or operator,(n m {gthtlT3*
<br /> eetitsh fa3dRtil Stitertpi $ trf3i4ity;regist ai::nts ;S T s c,t;sli of b}>
<br /> any Federal or State agency as well as non-petroleum US'1`s are exempt from this ttquircment.
<br /> VT.LEGAL NOTIFICATION AND BILLING ADDRESS ,
<br /> Check ONE BOX for the address that will be used for BOTHLEGAL AND BILLING.NOTIITC I7Q1S.
<br /> TANK OWbillk-OR,AU9IORIZEDREPRE5FiNTATIVE:MUSTIGAIAtlli> 31' ]z l I',A€��MCA'I'1313. I.t:SI,C,llt:)tiSZAaµ
<br /> 23114AY,'ER 16,CAL Hi ORNIA CODE OF REGU LA'IIONS:J.' `* r
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<br /> .UCTION EOR THE LOCAL AGENCIES
<br /> The county an jurisdiction numbers are predetermined and can be obtained by c ng tha SW1 I3gard j9I�i)2�7-4r3O3 Ilre laedily uqk cr maybe
<br /> %'assignedby the 166Yhgeat*;however,this number must tie numerical and cannot nta t arr}l alphik l*kracters 91f the local ay,(y pref-L•ts
<br /> the state Board to assign,the facility number,please leave it blank.
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<br /> IT IS THE RtMI'.lNSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY.TO TIIE ACCUR Y OP-THE.
<br /> INFORMtliTfC3Ts1.:9'Illb`APP11CATIMCANNOT BE PROCESSED IF TH9DOE raCC:OUN11'NA MT3ER IS NOT FILLED IN. `lfli LOCAI,
<br /> . •AGENCJS-RE,S3'�sSIi3LE FOR THE COMPLETION OF TNR- CAGAL AGRNCY;USE-Q0IIw�-Ilii ORYlA1TON 80X AND,FOR
<br /> FORWAItI)Lt"G.ONE I ittii"A"AND ASSOCIATED FORM"13'gs)' TH6 FOLLOWING:AD15RF SS. THE LOCAL AGENCY S961A,D
<br /> RETAIN TIIE ORIGINAL&AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> -:RETAINED BY THE TANK OWNER.
<br />..'._ .MMP+it1]�v..:'�MYia.:.'3 .rs.,. v::+.^•Y..'• - .. ...:... . -._ ,,.a.:'.li!'A:S'4ns!-N T.IKt-'sA#tt«-zWOR....-.r5.,-. ... .,.. ..
<br /> i STATE OFCALIFORNIA
<br /> STE WATER RESOURCES CONTROL BOARD
<br /> DATA-PROCESSING CENTER
<br /> P.O.BOX 527
<br /> Y'TA
<br /> v, F#ifj120[3t
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