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TSTRPCTIONS FOR COMPLETING FORM "All
<br />GENERAL INSTRUCTIONS:
<br />SECTION 2711 OF T'IT'LE 23, CI IAPTER 16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 23286, 25287, AND 2-5289 OF CHAPTER
<br />63, DIVISION 20, CALIFORNIA TIFALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br />1. One FOWN1 "A" shall be completed for allN EW 11 M -MIT CHANGES or any FACILITY/SITE INFORMATION CHANGES,
<br />2. SUBMI`F ONLY ONE (1) 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 APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br />4. PILase type or pruit clearly all requested information.
<br />S. Use a hard point writing instrument, you are making 3 copies,
<br />6. Tank owner must submit a facility plot plan to the local. agency as part of the application showing the location of the USTs with respect to
<br />buildings and landmarks [Section 2711 (a)(8), CCR].
<br />7. Tank owner Must submit documentation showing compliance with state financial responsibility requite.ments.to the local agency as part of the
<br />application for petroleum USTs [Section 2711 (a)(I 1), CCR).
<br />TOP OF FORM: "MARK ONLY ONRII'EM"
<br />Mark an (X) in the box next to the item that best describes the mason the form is being completed,
<br />FACIIITY/SI'Fi�','INFOItN4A'I'ION & ADDRESS (MUST BE COMPLETED)
<br />I, Record name and address (physical location) of the underground tank(s).
<br />NOTE: Address MUST have a valid Physical location including city, state, and zip code.
<br />P.O. BOX NUMBERS ARE. NOT ACCEPTABLE.
<br />Include nearea.cross street and name of the operator,
<br />2. Phone number must have air area code. If the night number is the same, write "SAME" in proper location,
<br />3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.).
<br />4. Check the appropriate box for TYPE OF BUSINESS,
<br />S. If Facility/Site 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 />7. Record the E.P.A. ID # or write "NONE" in the space provided.
<br />11. PROPERTY OWNER INFORMATION & ADDRESS (.N,,IUST BE COMPLETED)
<br />Complete all items in this section, unless all items are the same as SECTION 1; If the same, write "SAME AS SITE" across this section. He sure
<br />to check PROPERTY OWNERSHIPTYPEbox.
<br />III. TANK OWNER INFORMATION & ADDICF.SS (-MUST BE COMPLETED)
<br />Complete, all itcrns in this section, unless all items are the same as SEC11ON 1; If the same, write "SAME AS SITE" across this section. Be Sure
<br />to chackTANK OWNERS TYPIC box.
<br />IV, BOATO) OFI.-.QUALF/ATION I. ST ST01tAGF.,. FLE ACCOUNT NUMBE.R (MUST BL COMPLEI I'D. SE'11' ARTICLE 5, CIIAPIT'R 6,75,
<br />DIVISION 20, CALIFORNIA 11FALTI I AND SAFETY CODE.)
<br />EInCTY0LIK (80F) US'I'storagc fee account nUffll.Wwhich is required before your Nmiit
<br />Registration wifli tiro B01," will onurc that you will receive a quarterly storage fee rett.-at in reporting the $0.006 (6ni.ill,".) )OIlon Ice dw, on che
<br />number of gallons placcd in your USI's. 'Ibe 13013 will code persons exempt from paying the storage f'vc so r_nlmwit nol be "';nI. If you do not
<br />have. an :account nwnbcr v,hll tho BOI.or if you have any questions regarding the I'CQ of cmnllptlons, ple,isc, call the BOL al., 916 ' ''12..9669 or wrotcx
<br />to the IME at the, follo'Alwig address Board of Equalization, Fucl Taxes Division, 11.0. Box 942679, S,MaTncolo, CA 9 12;-,%'�,
<br />V. Pf"IROLEI.,M U'S I'l-IINANCIAL RESPONSIBILITY (MUS -1 BE CO-MI)LE"111) vOR I'l OT 1;
<br />U'ST, ONL)'_SE F' S 1 �C I iONS 27%'!1 )"S}
<br />OFTITLE 23, CIIAPI-Ek 16, CAILIFORNIA CODE 01: REGULATIONS,)
<br />Idcnt 1y
<br />itic ni�Zhtxlts) u,cd by wl: owllcran-Vor cperator, in rilectijig the Federal and Stato I ir anui<d �C�Ponsil.ih y kcl,i,iw,' 1"'S, !'s J by
<br />any T'edcrA of State igcncy as well as nonjxcuolewll UST's are exernpl, front this Kpujiiclmelnt.
<br />VI. LEGALN011FICATION AND BILLING ADDIdE'SS
<br />Check ONEBOX for the address that will be used .for BOTH LEGAL AND BILL1,NG N0TIIqCA'j IONS,
<br />TANK OWNERIOR AUT110ICZE'D R13PRF.SENTATIVE MUST SIGN AND AS INDICAII`Dt.SEF'2711
<br />(a)(13) OFTITIA; 23 ClIAI1ITR 16, CALIFORNIA CODT -OF REGULATIONS.]
<br />INSTRUMION FOR Till" LOCAL AGENCIES
<br />The county all j- "1riS(I*CLi0n rul-113Cr, are pred-Leralined and can Enc. obtained by calling the State 3oard It"1`2" I Inay '-
<br />assigned by the Milliber must be nurneiicid and cannot contain any alphabcic!! C
<br />pre.jrs
<br />the State llo,ud to assigiw who facility number, please leave it blank,
<br />IT is Tllli Rl".S110NISMILITY OFTITE LOCAL AGENCY THAT INSPECTS THE FACILITY '10 VERIFY THE ACCURACY OF '11TI1,
<br />INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BOI,, ISNOT' FILLED IN, '11TELOCAL
<br />AGENCY IS RI,'SPONS"BLE, FOR THE COMPLETION OF THE "LOCAL AGLNCY USE ONLY" INFORMATION BOX AND FOR
<br />FORWARDING ONE FORM "A" AND ASSOCIATED FORM *'B`(s)TO THE, FOLLOWING ADDRESS. THE LOCAT, AGENCY SHOULD
<br />RETAIN TIll.; ORR.'il_NALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDR1.,.SS,TIIL PINK COPY SHOULD BE
<br />RE"I'AINE'D BY'l HE, TANK OWNER.
<br />STATE OF CALIFORNIA
<br />STATE WATER RESOURCES CONTROL BOARD
<br />C/O S.W.E.E.P.S,
<br />DATA PROCESSING CENTER
<br />P.O. BOX 527
<br />PARAMOUNT, CA 90723
<br />3193 FOR012OR1
<br />
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