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INSTRUSIONS FOR COMPLETING FM "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CIIAP'TIiR 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA TTEALTIi AND SAI^ETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES.
<br /> 2. SUBMIT 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. Please type or print clearly all requested information.
<br /> 5. 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*[tAnspect to
<br /> buildings and landmarks[Section 2711 (a)(8),CCR]. .
<br /> 7. Tank owner mus t 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)(11),CCRI.
<br /> TOP OF FORA:".MARK ONLY ONE ITE',"I"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> I. 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,and zip code.
<br /> P.O.I3OX NU.IBERS ARE NOT ACCIEPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSINI:-.SS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate lx>x for TYPE OF BUSINESS.
<br /> 5. 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,I'D 4 or write"NONE"in the space provided.
<br /> II. PROPERTY O'KNE R INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1;If the same,write"SA.IE AS SITE"across this section. Be sunt~
<br /> to check PROPERTY OWNERSHIP TYPE.'box.
<br /> I:LL'h�2NK OWNER EsFORMATIO„ti&ADDRESS(11UST BL COMPLETED)
<br /> Complete all iteans in this section,unless all items are the same as SECTION l;If the same,write"SA.IE AS STIT3"across this section. Be sure
<br /> to check TANK O\VNI:RS TY'I1E box.
<br /> TV.BOARD 01�EQUTA1.1"I..ATTON UST STORAGE FIM ACCOUNT NUMBER( ,MUST'BI:CO.IPLET'I:D.SI I::ARTICLI 5,CHAT-FER 6.75,
<br /> DIVISION 20,CALIFORNIA II1 ALTA AND SAFIiTY CODE.)
<br /> finger your Board of I:oluuliraticzn M OIE)US f storage fee account number which is required your permit application can be processed.
<br /> Rei;stratwrl frith the B01:will ensure that you v ill receive a quanerly storage fee return in reporting the$0.W6.(6niills).per gallon fee due on the
<br /> numb-r of g:dlons;il x:cd in your t tS'ls. Tlnc 110I3 Hill code persons exempt.from paying the stotat;e fee.so retums will not ha tient.. Ifyou do not
<br /> have an account number w1th tlne'BO. ur if yoga havoc any questions regarding die fee or excrnpt.ions,phase tall the 1101 at.916-322 960)or write
<br /> to the BO,al the fo lo- ;ng ad,11,ss Hoard of Equalization,Fuel Taxes Division,P.O.Box 942S79,Sacramento,CA 94279 01001.
<br /> V. PEIROI_LL�%9 i'S 1'FINA\C:IAL,Rf.yPONSIli:,..ITY(11UST BE COMPI-bTED FOR PEI ROLEEUM.;S'ls ON l,Sl:I iii{"1 IONS 2711
<br /> OF TTTI E"23,CHAPTER 16,CAI-11 O_ZNIA CODE OI RI�:GU•LATIONS.)
<br /> Iden6Jy tl.; r.ncth:xi(sr u. cd by tltc owner andror operator,in mceting the Federal and State fin:,rncial responsibility mquirdtnonts.USTs owucd by
<br /> any I era'or S,aLc agcu.:y as well as nein-lxtrolcum UST"s arc exempt from this requiremem.
<br /> VI.LEGAL'v0111r1CATION AND BILLTNCr ADDR1 SS
<br /> Check ONF T?€:;tX for the address that will be used for BOTH LEGAL AND BILLING,NOTIFICATIONS.
<br /> TANK OWNER OR AUT110R1ZED RI;PRLSE.NTATIVE MI 3 T SIGN AND DATE TTIF.FORM AS LNDIC:AT'ED, IS]-,E SIiChIONS 2711
<br /> (a)(13)OF TITLE'23 CHAPTER 16,CALIFORNIA CODE Or REGULATIONS,]
<br /> INSTRUCTION ItOR T111"LOCAL.AGENCIES
<br /> The county an,jurisdict,ion nurinlx rs are predetemni.ned and can be obtained by calling the State Board(916)227-4303. The facility number may be
<br /> assigned by the local agency;hot over,this number must be numerical and cannot contain any alphabetical characters. If the local agency prefers
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS"Tllii RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY 'CO VERIFY TIME ACCURACY OF THE
<br /> INFORMATION, TI IIS APPLI.CATTON CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THELOCAL
<br /> OCAL
<br /> AGENCY IS RESPONSIBLE FOR TIIE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING;ONE DORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> R1:ETAIN TIIE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RIETAINED BY 111I:'I'ANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATL"^WATER RESOURCES CONTROL BOARD
<br /> CIO S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 193 FORD12ORI
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