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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23.CHAPI`ER Its,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 252859 OF CHAPTER
<br /> .7,DIVISION 20,CALIFORNIAHEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN L S"1"OPENATIN(I PERMIT.
<br /> 1, One FORM"A"shall be completed for all NEW PERMIT CHANGES or any F°ACILITY/SITF INFORMATION CHANCES,
<br /> 2. SUBMIT ONLY OITE(1)LrC?RM"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 INSPEiCTOR,
<br /> 4- Please type or priAt clearly all requested information.
<br /> 5. Use a harm point writing instrument,you are making 3 copies,
<br /> 6, Tank owner must submit a facility plot plan to the local agency as hart of the application showing the location of the USTs with respect to
<br /> buildings and landmarks(Section 2711 (a)(S),CCR],
<br /> 7 Tank owner€retest submit documentation showing compliance with erate financial responsibility requirements to the local agency,as least of the
<br /> application for pttrolexrn USTs[Section 2711(a)(i 1),CCRJ,
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Dark an(X)in the box next to the item that hest describe,,the reason the form 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 /> NOTE: Address MUST have a valid physical location including city,state,and zip code.
<br /> P.0,BOX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area coda. If the night number is thesame,write"SAME"in proper location.
<br /> 3. Check the appropriate boa for TYPE OF BUSINESS O NERSHIP(ex.CORPORATION,INDIVIDUAL,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:NUNIBER of TANKS at this SITE.
<br /> 7. Record the E.P.A..IU#or write"NONE"in the space provided.
<br /> 11, PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are rhe same as SECTION '1;If the same;,write"SAME AS SITE"across this section, Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box..
<br /> 111,TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items'aare the saine as SECTION I:If the same,write"SAME,AS SITE"across this s,ecd gin. Besure
<br /> to check TANK OWNERS TYPE box,
<br /> Its.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BF,COMPLETED,SEE.ARTICLE,5,CHAPTER 6.715,
<br /> DIVISION 20,CALIFORNIA HEALTH AND ,A E Y CODE.)
<br /> Enter your Board of Equa i a6on('BOB)UTST storage fee account.number which is r uimd before tier pezroit application can be processed,
<br /> Registration with the EOE will ensure that you will receive a quartarly storage fee return in reporting tft°,°per gallon fee due on the number of
<br /> gallons placed in your USTs. The BOE will code persons exempt-from paving the storage fee so returns will not be scat€_ If you do not have an
<br /> account number with the BOE or if you haveany questions regarding the fee or exemptions,please;call the BOE at 910.322-9669 or write to the
<br /> BOE at the following address Board of Equalization,Fuel Taxes Division,P,O,Box 942579,Sac zcr ento,CA 942-79,0001,
<br /> V. PETROLEUM UST FINANCIAL NCI.;L RESPONSIEBIL,ITY(?AUS`I`BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS SS 2711(a)(I 1)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS-)
<br /> Identify the method(s)used by the owner and/or operator,in meeting the:Federal read State financial responsibility requirements.USTs owned by
<br /> any Federal or State agency as well as nose-petroleunc LISTS are exempt from this requirement.
<br /> VI,LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the a€habeas that will be used for BOTH LEGAL,AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE C RIA AS INDICATED. (SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,,)
<br /> INSTRUCTION FORTHE LOCAL AGENCIES
<br /> The county and jurisdiction slumbers are predetermined and can be obtained by calling the State Board(916)227-4101 The facility number may
<br /> be assigned by the local agency,however,this number must he numerical 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 TETE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE,
<br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BOB ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL
<br /> AGENCY Ls RESPONSIBLE,,FOR THE CQMPLFFION OF THE "LOC"AL,AGENCY,USE ONLY",INFORMATION BON., THE LOCAL
<br /> AGENCY SI-101JI.l RETAIN THE ORIGINAL, AND YELLOW CONIES, THE:PINK C 013Y STIOULb BE RLT`AINI L3 BY THE TANK
<br /> OWNER,
<br /> X195
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