|
INSTRUCTIONS FOR COMPLETING FORM toff,
<br /> rk INSTRUCTIONS r
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA COBE OF REGULATIONS AND SECTIONS 25286,25281,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN IST OPERATING PERITIT,
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2, SUBMIT ONLY ONE(1)FORD"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3, This form s ould.be completed by either,the PERMIT APPLICANT or the LOCAL,AGENCY L,INDERC;I2C}UNI)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 plat plans to the local agency as part of the application shouting the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(8),CCR[:
<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 best describes the reason the form is being completed.
<br /> F. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> I. 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 ACCEPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same,write`SAME"in pi6per,16cation,
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box fon TYPE OF BUSINESS,
<br /> 5. If Facility/Site is located within an Indian reservation or other Median trust lands„check the tsox 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 /> II. PROPERTY OWNER IN'FORMATI€)N&ADDRESS(MUST BE COMPLETE[))
<br /> Complete all items in this section,unless all itpnss are the 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 /> Coffiplete all items in this section,unless all items are the same as SECTION I;If the same,write"SAME AS SITE"across this section. Be snare'
<br /> to check TANK OWNERS TYPE box,
<br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE E 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your Board of Equalization(BOE)UST,storage fee account number which is required before youi permit'application can be process!ad6 '
<br /> Registration with the BOB will ensure that you will receive a quarterly storage fee return in reporting the per galm'n fee due on the number of
<br /> gallons placed its your USTs. The BOE will code persons exempt from paying the storage fee so returns will not be sent. If you do not leave 6
<br /> account number with the BOB or if you have any questions regarding the fee or exemptions,please call the BOB at 916-:322-9669 or write to the
<br /> BOB at the followi <i address Board of 8qualization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0001,
<br /> V. PETROLEUM LIST°FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY.SEE SECTIONS 2711(<a)(11)
<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 and State financial responsibility requirements.TISTs awned by
<br /> any Federal or State agency as well as non-petroleum LISTS are exempt from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOAC for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS, ,
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND LATE TETE FORM AS INDICATED, (SEE SECTM141S 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,]
<br /> INSTRUCTION FOR THE LOCAL,AGENCIES
<br /> The county'nd jurisdiction numbers are predetermines)and can be obtained by calling the State Board(916)227-4303. The facility number may
<br /> be assigned by the local agency;however,this number must be 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 THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF TETE BOE ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL`
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL AND "YELLOW COPIES. THt PINI{.COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
<br /> AOL
<br /> 6:`95
<br />
|