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<br /> INSTRUCTIONS FOR COMPLETING FORIM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE _RF.Gi_1LATIONS AND SECTIONS 252867,252117,AND 25289€.)F CHAPTER
<br /> 6:7;DIVISION 20,CALIFORNIA HEALTH AND SAFETY CC}I�B RQUIRE€WNERS TO APPLY FOR AN to sT OPERATING PERMIT,
<br /> 1. One FtJR v1"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/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 form s ould be completed by eithenthe 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 crust 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),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 UST's(: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 /> I. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> i. Record name and address(physical location)of the underground tank(s).
<br /> NOTE, Address MUST haven valid physical location including city,state,and zip code.
<br /> P.C.BOX NUMBERS ARE NOT ACCEPTABLE,
<br /> Include nearest cross street and nacre of the operator.
<br /> 2. Thane number must have act arca code. If the night number is the sante,write"SA 1E"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 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 NUMBER of TANKS at this SITE.
<br /> 7. Record the E.P.A.ID#or write"NONE"in the space provided.
<br /> IT. PROPERTY 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 PROPERTY OWNERSHIP TYPE box.
<br /> 111.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 EQUALIZATION UST"STORAGE FEE ACCOUNT NUMBER(DUST BE COMPLETED.SEE ARTICLE 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 your permit application can be processed. '
<br /> Registration with the BOE will ensure that yoi will receive a quarterly storage fee return in reporting the per gallon fee due on the number of
<br /> gallons placed in your USTs. The.BOE will code persons exempt from paying the storage fee so returns will not be sent. If you do not have an
<br /> account number with the BOB or if you have any questions regarding the fee or exemptions,please call the BOE at 916-322-9669 or unite to the
<br /> -BOE at the:foilowim,address Board of Equalization.Fuel T'nkes Division,P,O.Box 942879,Sacramento,CA 94279-0001.
<br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (a)(I l)
<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.USTs owned by
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL,AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE TETE FORM AS INDICATED. (SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE€3F REGULATIONS.]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined 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 TIME
<br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BOB ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL.
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOC4,L AGENCY USE ONLY"INFORMATION BOX. THE LOCAL.
<br /> AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINER BY THE TANK
<br /> OWNER,
<br /> 6195
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