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INSTRUAONS FOR COMPLETING FAM "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 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.M"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INT-ORMATION 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 PElo—IMIT 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),CCRI.
<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 /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that Nest describes the reason the form is being completed.
<br /> L FACILITY/SITE TNFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name--:l address(physical location)of the underground tank(s).
<br /> NOTE- AH-, —NIUST have a valid physical location including city,state,and zip code.
<br /> PDX NUM13ERS ARE NOT ACCEPTABLE.
<br /> est cross trect and narne of the operator.
<br /> —,r
<br /> 2. Phone n `,avc i° --a code. If the night number is the same,write"SAME"in proper location.
<br /> 3. Check the approf ,!i;t,4-K i--TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION.RiDIVIDUAL,etc.).
<br /> 4. Check the appropi.,!c bl-c.,,to-,I YPE OF BUSLNES&
<br /> 5. If Facility/Site is located within air 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#or write"NONE"in the space provided.
<br /> 11. PROPERTY OWNER LNTORMATION&ADDRESS(NNIUST BE COMPI.LTED)
<br /> Complete all items in this section,unless all,items are the same as SECTION 1;If the same,write"SAME AS SI'Z'E"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> 11.1.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 SI'Z'E"across this section. Be sure
<br /> to check TANK OWNERSTYPEbox.
<br /> IV,130AIZD OFEQT,-ATJZATIO-, UST STORAGEFEE ACCOUNT NUMBER(IMUST BE COMPLETED.SEE ARTICLE 5,CIIAI)'f'l..-,R 635,
<br /> DIVISION 20,C',,J FORNIA —ALI'll AND SAFETY CODE.)
<br /> Ent of B. on(1101")UST storage fee :!number which is required before your permit application can be picices,,icd,
<br /> iciiswe lhat}ou will receive a:,I—irlerly storage fee returnt in repon.ing theO.006{t;r,si_' vrgallon fee,due on the
<br /> US: AIS exempt from paying the\te
<br /> , —:1 c, -sent, If you do not
<br /> ,;iis regarding die fee orexcoip;,!�,�,
<br /> Division,P.O.Box 942879,
<br /> V. PETR, 'ST' V,:ST COMPLE"T"ED FOR PEIROLEUM USTs ONL'�, ION'S 2711 (s)(S)
<br /> OF"hl" 'NIAC( ;a,-LATJONS.)
<br /> ri,xcr and., r.no-'elilig the Federal and.Staic financial---
<br /> any
<br /> -Aernpt from this requir--ment,
<br /> VI.LEGAL Nu i'10,\ -,j)jv;
<br /> Check X for ihc dl bal for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OR AUT! ',I)REPRF:�.'ITATIVE MUST SIGN AND DATE THE FORM AS LNDICATED. [SEE SEC TIONS2711
<br /> 23 CHAIII[.ik 16,CAIIIFOR.'NIA CODE OFREGULA'l`lONSj
<br /> INSTRUCTION FOR THE LOCAL AGENCIliS
<br /> The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number may be
<br /> assigned by the local agency,however,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 /> ITIS Till-' RESPONSIBILI'T'Y OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION. T111S APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER 15 NOT FILLED IN. THE LOCAL
<br /> AGENCY IS R13SPOINSIBI-L 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'I']iL-'OIZIGI.NAI—';AND FORWARD THE YELLOW COPIES TOTHE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BY THE TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C/O S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O,BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3193 FOR012ORI
<br />
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