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INSTRUSIONS FOR COMPLETING FOM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 Oh`TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA IIEALTI I AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PEIUWT 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 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 shoiring the location of the USTs with respect to
<br /> buildings and tara!rnarks[Section 2711 (a)(8),CCR].
<br /> 7. Tank owner inw,submit documentation showing compliance with state financial responsibility requirements to the I"agency as part of the
<br /> application for petroleum USI's ISeclion 2711(a)(I 1),CCRI.
<br /> TOP OF FORM:".MARK ONLY ONE rm-l"
<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 /> 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.13OX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest cross street and natne of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate box forTYPE 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 NUMBLIZ of TALKS at this,SITE.
<br /> 7. Record the EP.A.ID 0 or write"NONE"in die space pruvided,
<br /> 11. PROPERTY OWNER I.NFORMATION&ADDRESS(MUST Bi-,COMPLETED)
<br /> Complete all iterns in this section,unless all items are the same as SECIION 1;If die same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNI.-I'RS 11111 TYPL 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 OWNERSTYPI:box.
<br /> IV.BOARD 01�EQUALIZATION US I'SJORAGE FEE ACCOUNT NUMBER(MLiS`1'I3I3 C01IPLf:'PLD.SI-13AR,ricuE 5,CIIAIYIER&75,
<br /> DIVISION 20,CALIFOI2NIA III.AL'I'll AND SAFETY CODE-)
<br /> Linter yourlioard of Ecriahi-nion(BOH)UST storage fee account number which is roquind ty-fore your penrnit application can be processed.
<br /> Rq'; tnmon with the BOE will clISUIC that you will receive a quarterly smage fee return in reporting the,$0.1006 pci gallon fco.clue on dic
<br /> numb o1g,:i1k,nspl.il-ad in your UsIs. 'fl-,Q 1301"will Code persons exerript from r-aying the storage fee.sc;-Qlurn.will not h,.;sent, It you dincit
<br /> have anacco'na imrnbL� ��iih ihBOI'u,d\ou have any questions rcgardling the tee or exompiiorq,please,call;he B *,at 910 1)2 9669 or write
<br /> to the BOF atihL folloV,11,t.11,t,tdlu-,�:(3ojdof 1.qualijation,Fuel"Taxes Division,11.0.3ox 942'S79,Saci4inento,CA 94279 Dol.
<br /> V. PETROLFUM',:,S I INANCfAl,lUISPONSJWIJTY(1Vus'r w-Complx--riu)FOR PEIR0I,I`1UN1 I-Sls ONI.y',SFE,Si,"C'I IONS 2711 (a)(S)
<br /> OFTITLE 23,C'11 A'-1'-1:R 16,CA'J1 OkZNIA
<br /> Iden:ft tho mwulodts)u—d by thc')tvAicr an iioi.opctator,in meeting the I-cdofal and State U'STS
<br /> any F-,.Icialot Si—c agcn,�y as we as non petroleum LSTs arc exempt from this requitcaicot.
<br /> VL LEGAL NOI 111CATION AND BILLING ADDRESS
<br /> Check ONE BOX for the adde,,,that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUT110RIZED RE.I'RF,SENTATIV7 Mt ST SIGN AND DATE THE,FOWIl AS INT)ICATED, [SEE SH'C'l IONS 2/11
<br /> (a)(13)OFTII LE,233 C11APTE'R 16,CALIFORNIA CODE 0!-REGULATIONS]
<br /> INSIRUCTION 14.)RTHE LOCAI,AGEINCIES
<br /> The couwy an jurisdiction nurnlxi s are pr(:dC1Cnnincd and can be obtained by calling the State Board(916)227-4303.
<br /> assigned by the local agency;how ever,this number must be numerical and catratot contain any alphabetical characters. If the local agency prefers
<br /> the State Board to assign the facility number,please leave it blank. I
<br /> IT IS THE RESPO',161BILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY TIIL ACCURACY OF IIIE
<br /> ]INFORMATION. "TRIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. Till, LOCAL
<br /> AGF'NCY 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 THE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RLI-AI-NED BY 111E.TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE W ATER RESOURCES CONTROL BOARD
<br /> C/o S.W.r,E.P.S,
<br /> DATA PROCESSLNG CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> FORD12ORI
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