|
INSTRUCTIONS FOR COMPLETING FORM "All
<br /> GENERAL INSTRUCTIONS:
<br /> SEG1-ION 2711 OF'IITLE.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 7'0 APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A”shall be completed for all NEW PM- MIT CHANGES or any FACILITY/SITE INFORMATION CHANCES.
<br /> 2. SUBMIT ONLYONE(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 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)(11),CCRI,
<br /> TOP OF FORM-"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the bosh next to the item that best describes the reason the fort 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.BOX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include,nearest cross street and name of the operator.
<br /> _.2. Phone number tilust have alt arca axle. If the night number is the same,write"SAME."in proper location.
<br /> 3. Cheek 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/Sue 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 /> 1 Rccord theZ.P.A.ID#or.-write"NONE"in the space provided.
<br /> 11. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this sectiou,unless all items are the same as SECTION l;if the same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> Ill-TAN�K OWNER INFOIZMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all"items to 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 EQUAl._IIAIION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CIIAP'I7.-�R 6.75,
<br /> DIVISION 20,CALIFORNIA IiEALTH AND SAFETY CODE.)
<br /> Enter your Board of Egnatixation(1101'.)UST storagc.fce account number which is required before your pom,it application can be.Processed.
<br /> Registration N%ith the!.EOL•.will cn Sure that you will receive a quarterly storage fee return in reporting the S0.(X)6(6miliS)per gallon fee dile on the
<br /> number of gallons placed in your UST's. The BOE will code persons exempt from paying the storage fee so return.,will not be sent.. If you do nci
<br /> Have an account number with the BOE or if you have any questions regarding the fee or exemptions,please call the BOE'at 916 3"_'2-0669 or write
<br /> to the BOE at the following address Board of Equalization,Fuel Taxes Division,11.0.Box 942879,Sacramento,CA 94279-0001,
<br /> 1.
<br /> V. PETROLEU.%1 UST!'INANCI.AL RESPONSIBILITY(MUSTBE COMPLETED FOR III',"I R01,E(M UST's ONI..Y,SL1,SFC IONS 2711 (a)(S)
<br /> OF 11 T 23,CI IAP1'ER 16,CALIFORNIA CODE O.F RECiL'1 ATI.ONS.)
<br /> Identify the nicthod(s)used by the Owner and/or operator,in nteetirlg the Federal and State financial responsibility requireiturtts.I.JS`i`S cv:mA by
<br /> any Fcdcral or State agency as well as nora-petroicum USTs are exempt from this requircrnent.
<br /> VI.LEGALNOTIFICATION AND BILI-ING ADDRESS
<br /> Check ONE BOX for the address that.will be used for BOTH LEGAL AND BILILING NO'11FICA1IONS,
<br /> TANK OWNI:IeOR AUTII0Rl2-ED REPRESENTATIVE MUST SIGN AND DATETHE FORM AS INDIC:AT IM tSEE.S CT'IONS 2711
<br /> (a)(13)OF TffI..E 23 CiIAIYY ER 16,CALIFORNIA CODE OF REGULA'FIONS.I
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-1303. The facility number may t+c
<br /> assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the local agency prefors
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS THE' RI.SPONS',B11-ITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILFI'Y'I'O VERIFY IIID ACCURACY OF THE
<br /> LNFORN ATION. TI 118 APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE I.00AI.
<br /> AGENCY 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 /> RI.:TAIN TIiI:ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BY'l IfE TANK-OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> 0/0 SW,E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAI_k1QUNT,CA 90723
<br /> t3 3 . FORD12DRI
<br />
|