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INSTRUISIONS FOR COMPLETING N frM "Alt GENERAL INSTRUCTIONS: SECTION2711 OF TITLE 23,CUAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER 6.7,DIVISION 20,CALIFORNIA HEALTII AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT. 1. One FOILM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES. 2. SUBMIT ONLY ONE(I)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site. 3. This form should be completed by either die PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 4. Please type or print clearly all requested information. 5. Use a hard point writing instmment,you are making 3 copies. 6. Tank owner most submit a facility plot plan to the local agency as part of the application showing the location of the USTs with respect to buildings and landmarks[Section 2711 (a)(8),CCR]. 7. Tank owner mo—submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the - application for petroleum USTs[Section 271!(a)(I 1),CCR]. TOP OF FOR-M:"MARK ONLY ONE ITEM' Mark an(X)in the box next to the item that best describes the reason the forth is being completed. I. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED) 1. Record name and address(physical location)of the underground tank(s). NOTE: Address MUST have a valid physical location including city,state,and zip code. P.O.I30X NUNIBERS ARE NOT ACCEPTABLE. Include nearest cross street and name of the operator. 2. Phone number must have an area code. If the night number is the same,write"SAME"in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.). 4. Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Site is located within an Indian reservation or other Indian tmst lauds,check the box marked"YES". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A.ID N or write"NONE"in the space provided. IT. PROPERTY OWNERINFORMATION&ADDRESS(MUST BE COMPLETED) Complete all items in this secuou,unless all items are the same as SIECIION 1;If the same,write"SANIE AS SPITE"across this section. Be sure to check PROPERTY OWNERSHIP TYPIE Not. IB.'TANK OW'NL:R INFORMATION&ADDRESS(.MUST BE COMPI..ETED) 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. Be sure to check TANK OWNERS I'Y'PE.box. IV.BOARD 01;EQUALIZATION US`I S'1 OR1(3E FEE ACCOUNT NUMBER(MUST III,COAPT EI ED.SEE ARTICI-F 5,CHAPII;R 6.75, DIVISION 20,CALIFORNIA I IEAIA 11 AND SAFETY COBE.) Enter your Hoard of Equalixstion(I3OE)US'I storage fee account number which is mquired before your permit applieaion can be processed- Rr;ielranion with the BC1E will ensure that you will receive a quarterly storage,fee retum in repoudug the$0,006(6nti0e)f,cr gallon fee due on the number of gallons placed in your US'Es "the BOG will code persons exempt front prying the storage fee so returns will not he Sent, if you do nca ha,c an ac count number with rite BOE or if you have any questions regarding We Ice or exemptions,please call the BUE aL 916-322 9669 or write to the BOIi a4 the following s.6lrus Board irf Equalixalion,Pucl Tates Division,P.O. Box 442879,Savnnmam,,CA 94279 0001. V. PE`IROI I L>t USGI IN 1NCL1L RLS.ONSIBB.Il'Y'CHCS"f BE COMPLE'I'EU FOR 1'EII20I EUa1 US f. ONLY,SEE Sl;( 110N;S 27l l fa)(S) OF TITLIi 23,CHAT'fISR 16,CALIFORNIA CODE O}r R;EGI➢.A'CIONS.) Identify the ntcthud(s)used by the owner and/or operator,in meeting the Federal and State fin-n, al respomibiiity requuc mutts L75`Is uwnnl by any Pedaal or State agency as well as non Petroleum USTs are exempt from this requirement. VI.LI:GAL NO"I IFICATION AND 131LL.ING ADDRESS Check ONE 13OX for the address that will he used for BOTH LEGAL AND BILLING NOI'IIICA'IIONS. TANK OWNER OR AU`I`HORlY.LD REPRESENTATIVEMISTSIGNAND DAIE THEFORM AS INDICA-IliD. [SFLSEC"HONS1111 (a)(13)OF TI"I LE 23 CHAPTER 16,CALIFORNIA CODE O` REGULATIONS.] 1NSIRUC'1TOIG I'OR'lllE LOCAL AGENCIES - - Ihe county an prisdicticn numbers are predetenruned and can be obtained by calling the State Board(916)227-4303. 'Rhe facility number may Nt assigned by the local agency;however,this number must be numerical and cannot contain any.alphabetical characters. If the local agency prefers the State Board to assign the facility number,please leave it blank. IT IS I LIE KESPONSIBILITY OF IHE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE LNFORMA'IION. TIES APPLICATION CANNOT BE PROCESSED IF THE HOE ACCOUNT NUMBER IS NOT FILLED IN. THELOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE I7ORN1"A"AND ASSOCIATED FORM"B"(s)TO TELE POLLOWLNG ADDRESS. THE LOCAL AGENCY SHOULD RUTAIN` III:ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS,THE PINK COPY SHOULD BE RF—FAI.NED BY IILP.TANK OWNER. STATE OF CALIFORNIA SPATE WATER RESOURCES CONTROL BOARD C/O S.W.E.E.P.S. DATA PROCESSING CENTER P.O.BOX 527 PARAMOUNT,CA 90723 3;99 FOp,.-.