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INSTRUCTIONS FOROh1FI,ETING FORM "A"
<br /> r,iNt12AL INSTRUCT10�5:
<br /> SECFION-271 F 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 USTOPERATING PERMIT.
<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)FORM'rA-"for a Facility/Sitc,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 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 USTs[Section 2711-{a)(11),CCRJ.
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item thatbest-describes the reason theform is being completed.
<br /> I. FACILITY/SITE INFOILMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name and address,(physical location)of thtunderground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city,state,and zip code.
<br /> P.O.BOX NUMBL'_RS,ARE RIOT ACCEPTABLE.
<br /> Include nearest Crn;;s;ueet and name,of the operator.
<br /> 2.'Phode number mug have aA"t" A code. If the alight 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 BUSINESS.
<br /> 5. If FacilityrSite 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 /> H. PROPERTY OWNER INFORMATION&ADDRESS(NIUST 13E 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 /> M.TANK OWNER I'NFORMAT'ION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this-section,unlcss'ill items are the same as SECTION 1;If the same,write"SAME AS SITZ::"across this section. Be sure
<br /> to check TANK OWNERS T'Y11L box.
<br /> 1V.BOARD OF EEtUAI.IZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEI:ARTICLE 5,CIIAIYII:?.R 675,
<br /> DIVISION 20,CALIFORNIA ILEALTII ANT)SAFETY CODE.)
<br /> Enteryour Board of Equalization(BOL:)UST storage fee accountrumberwhich is required before your Ix,m.it application.;au be proccssed.
<br /> Registration with the 130E +•ill ensure that you will receive a quarterly storage fee return in reporting the SO.`ft(61mfl�)per gallon fee due on Lhe
<br /> number of gallons placed in your US I's, The BOE will code persons exempt from paying the storage fee so returns will riot be scr,t.. If you do neu
<br /> have an account numbcrwith the BOE or if you have any questions regarding the fee or exemptions,please call the lit I' at 916 322 600 or write
<br /> to the BOE at the following address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-00UL
<br /> V. PEIROLEUM Lb 1•FINANCIAL RLSPONSIBILITY(MUST"BE CONIPLETED FOR PhFROTALUNI LSTs ONLY,SEE iFC1 IONS 2711 (a)(;;)
<br /> OF TITLE 23,CHAP1'L'R 16,CALYOR:N1A CODE OF REGULATIONS.)
<br /> Identify the n�cthoi(s)ust-}by the owner and/or operator,in meeting the Federar and Statefinancialrc.sponsibi.ay rcyt 4r.,...:,tt.: 1.'S'I s oo,tCd 1:y
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILI..I.NG ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNED OR AutilORllED REMER SEa'NTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. 1SEI.St.(T IONS 2711
<br /> (a)(13)OF-FITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.]
<br /> INSIRUCTION FOR'THE LOCAL.AGENCIES
<br /> The county art jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303. I ll4'.I Trottl!y nurnbcr tttay!
<br /> assigned by the Tocil ajetivey`h6*cvei,this number must be numerical and camiot contain any alphabetical characters. If the local agency prefers
<br /> the State Board to assign the facility number,please leave it.blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILFI'Y TO VERIFY THE ACCURACY OF THF.,
<br /> INFORMATION-: THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED I.N. TIM LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY" INFORN'IATION BOX AND FOR
<br /> FORWARDING ONE FORM"A"AND ASSOCIATED FORM"I3"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETALV THE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BY TfiE TANK OWNER.
<br /> STAT'E'OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD ii f
<br /> C/O S,W.Ii.E.P.S..
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAM0,0L CA 90723
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