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INSTRUCTIONS FOR COMPLETING FORM "Ant
<br /> GENE RAL INSTRUCTIONS:
<br /> SECDON 2711 OF 1ITLI:23,CIMAPT E'R 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FOR-%1"A"shall be complciad for all NEW PERMIT CHANGES or anyFACILTIY/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 fort 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 with respect to
<br /> buildings and landmarks[Section 2711 (a)(8),CCRJ.
<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)(1 IX CCRJ.
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that best.describes the reason the form is being completed
<br /> I. FACII.ITY/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.BOX NUMBERS ARE NOT ACCEVrABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. If the nig}ii 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 BUSI:NIiSS.
<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.ID fi or write"NONE"in the space provided.
<br /> Il. PROPERTY OWNER INFORMATION&ADDRESS(.IMUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SEC"IION 1;If the same,write"SAME AS SI'Z'E"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPIi box.
<br /> III.TANK OWNER 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"SAME AS SITE"across this section. Be sure
<br /> to check TANK OWNERS"TYPE box.
<br /> IV.BOARD OF EQUAL_ZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED,SEE ARTICLE 5,CHAVI"ER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH ANT)SAFETY CODE.) "
<br /> Enter your Board of Iiqualtz:ttioa(1301,0 UST storage fee account number which is required before your Nnnit application cant be,I:rroces5ed_.
<br /> Registration with the BOE,w;Ii en,urc that'you will.receive a quarterly storage fee return in reporting the SO.kX)6(6nnd Pcga;lon fees due on the
<br /> number of gallons piacad in your US I's. 'IZtc BOL;will code persons exempt from paying the storage fee sea returns wall noa be soca. If you do not
<br /> have an account number with the BOZ:or if you have any questions regarding the fee or exemptions,please call the BO!`at 916 3"220669 or write:
<br /> to the 130E at die follow ung address Bcmrd of Equalization,Fuel Taxes Division,P.O-Bax 942879,Sacramento,CA 94279_0001•
<br /> V. PEIROI.EU?,M US['FIINANCIAL.RESPONSIBILITY(MUSTBF COMPLETED FOR PETROLF.UNI US'I's ONLY,Slit,SECTIONS 2711
<br /> OF ITTLE 23,CI IAI'-I"ER 16,CAI.1GOi2NIA CODE OI'RE(IULATIONS.).
<br /> Identify the aneth<xi(s}used by t1tL.cnwner,and/or operator,in meeting the Vederarand State financial responsibility,requu in_;al i 5"I's ov rrcd by
<br /> any l ederat or State agency as well as non-petroleum I IS`Ts are exernp,from this rNuircmcnx.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE 13OX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK OWNER OR kUTI IOR ZE.D RE PR PSENI'ATIVB MUS-fSfGN AND DATE TTIE F0104 AS INDICATED. (Sl.t:5r,(:,"i'K)tiS 2711
<br /> (a)(13)OF TITLE:23 CHAPTER R 16,CALIFORNIA CODE OF R LGCLATIONS.J
<br /> INSTRIICITON FOR'1111"LOCAL AGENCIES,
<br /> The county an jurisdiction numbers are Predetermined and can be obtained by calling the State Board(916)227-1303,. The facility number may he
<br /> assigned by the loc.,l agency;however,this number must be numerical and cannot contain'any alphabetical characters. If the local agency pielors
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS THE.' RESPONSIBILITY OF THE: LOCAL AGENCY THAT INSPECTS TYLE FACILITY TO VERIFY THE ACCURACY OF TTIE
<br /> INFORMATION. T'I IIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLI:M IN. THE LOCAL.
<br /> AGENCY IS-RESPONSIBLE, FOR THE COMPLETION OF THE "LOCAL AGENCY-USE ONLY" INFORMATION BOX AND FOR.
<br /> FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN TI11i ORIGINAIS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED 13Y I IIF TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE 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 /> 3,193 FORD12ORI
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