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<br /> INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,C14APTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,252117,AND 25289 OF CHAPTER
<br /> 63,DIVISION 20,CALIFORNIA HEALM4 AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN USTOPERATING PERMIT,
<br /> 1, One FORM"A"shalt be completed for all NEW PERMIT CHANCES or any FACILITYISITE INFORMATION CHANGES.
<br /> 2, SUBMIT ONLY ONE(I)FORM".A"for a Facility/Site„regardless of the number of tanks located at the site.
<br /> 3. This form should'e completed by either the PERMIT APPLICANT ANT or the LOCAL.AGENCY UNDERGROUND TANK INSPECTOR,
<br /> 4. Please tyle 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 with respect to
<br /> buildings and landmarks[Section 2711(a)(fl),CCF).
<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)('I 1),CCR].
<br /> `IOP OF FORM: MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that hest describes the reason the forma 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 /> NO'T`E: Address MUST have a valid physical location including city,state,twd zip code.
<br /> RO,BOX LUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code.. If tire might number is the samae,write"SAME"in paper location.
<br /> 3. Check the appropriate box Cor TYPE OF BUSINESS OWNERSHIP(ex,CORPORATION,tt*aDIV(DUAL,etc.).
<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 lands,check the box marked"YES"
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> T Record the E,P,A.ID#or write"NONE;"in the space°provided.
<br /> 11, PROPERTY C'1WNER.INFORMATION&ADDRESS SS(M8JS'FEE COMPLETED)
<br /> Complete III it-tus in this section,unless all ite'n s are that,same a,;SECTION I a If the s uoc.,write"SAME AS SITE"across this section. Be sure,
<br /> to check PROPERTY OWNERSHIP TYPE box,
<br /> 111,"TAMC OWNER INFORMATION A ADDRESS(NIUST BE COMPLETED) j���
<br /> Complete alt items in this section,unless all items an--the same as SECTION I,If the sarta ,carte"SAME,AS SITE"across this suction, Be sure
<br /> to check TANK OWNERS TYPE box.
<br /> TV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE €3MPLE`I`ED.SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your Board of Eduat;ration(BOE)UST storage fee account r amber which is required before your permit application can be processed,
<br /> Registration with the BOB will erasure that you will receive a quarterly storage fee return to reporting the per gallon fee clue on the number of
<br /> gallons placed in your USTs. The BOB will guide personas exempt from paying the storage fee so returns will not be sent_ if you do not have an
<br /> account number with the LIGE or if you have any questions regarding the fee or er.,nf do,s,please call'the BOE at 916-322-9696or write to the
<br /> BOE at the follow°imiz address Board of Ecpuilizafion,Fuel Taxes,Di vimou,RO,Box? Sacramento,.2 79,Sac„ nto,CA 94279,,,')001
<br /> V, PETROLEUM UST FINIA CIAL RESPONSIBILITY(MIDST BE COMPLETED FOR PETROLEUM USTs ONLY,SEF,SECTIONS 2731 (a$)(I 1)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,)
<br /> Identify the method(s)used by the owner andtor operator,in rneeting the;Federal and State financial responsibility requirements,USTs owned by
<br /> any Federal or State agency as well as non-petroleum LIST;are exempt from this requirement,
<br /> SII.LEGAL,NO'T'IFICATION ANIS BILLING ADDRESS
<br /> Check ONE BOX for theaddress that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TAMC 43Lt'NER OR A THORIPFD REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATE[), [SEE SECTIONS 2711
<br /> (a(13)OF TITLE 23 CHAPTER 16,CAl.IF0)RNIA CODE,OF REGULATIONS]
<br /> INSTRUCTION FOR THE FOCAL AGENCIES
<br /> The county and jurisdiction numbers are predeterrmined and can be obtained by salting the State Board(916)227,4303. The facility number may
<br /> be assigned by the local agency;however,this number rust be nurnericai 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 TGIF RESPONSIBILITY OF'THE LOCAL, AGENCY THAT INSPECTS THE FA,CIL a f TO Vf RIe Y THE ACCURACY OF THE
<br /> TNI°62It5TATIC , TF1S APPL IC"ATI'OIsI C A PdC9'f BT,1 PRL7C ESSF�IF THE BOBACCOUNT NUMBER IS NOT FILLED Its. THE LOCAL
<br /> AGENCY IS RESPONSIBLE FC)R THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX, TETE LOCAL
<br /> AGENCY SI-ItJL,`LD RETAIN Till" COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
<br />
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