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INSTRUCTIONS FOR COM L `"
<br /> GENERAL INSTRUCTIONS-
<br /> SEC ION 2711 OF TITI.r 23,CHAI'°T'ER 16,CALIFORNIA CODE OF REGULAn0NS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH,AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN LST OPERATING PI-MMIT.
<br /> 1. One,FORM"A"shall be completed for all N 1"s'*Y PER.'U T`CHANGES or any FACIL,IT Y ISTI"E INFORMATION CHANGES,
<br /> 2. SUBTAIT ONLY ONE(1)FORM"A,'fear a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3: This form should be completed by either the PERIMIT APPI-ICANT or the LOCAL AGENCY UNDERGROUNNI)TANK INSPE(770R.
<br /> 4. Please type or print clearly all,requested information.
<br /> 5. Use a hard point writing instrument,you are making 3 crsrr:ens.
<br /> 6. Tank owner must submit a facility pleat plan to the Kcal agt trey as part of the application showing the:location of the U'STs with respect to
<br /> buildings and landanarks tSect€on 2'711(a)(g),CCRI.
<br /> 7. Tank owner must submit documentation showing cornla e rice with stag:financial responsibility requirements to the local agency as part of the
<br /> application for Petroleum USTs[Section 2.711(a)(11),C.x I li
<br /> 'I'01'OF FORIaS:":Nf ARK C1,I.Y ONI.:I'I E,N,I"
<br /> Mark an(7C)in the box next to the tient that best describes the reasser the fonn is lasing completed,
<br /> I. FACILITY/S.111 INFORMATION&ADDRESS(NIUS`I'i3} COMPLETED)
<br /> 1. Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address MUST have a val,.d physical location including city,state.,and zip code.
<br /> P.O.I3OX N UMBEMS ARE-NOT ACCEf TABLE.
<br /> Include nearest cross street and narne of the operator,
<br /> 1 Phone number must have an area code. 3f the night number is the same,sprite"SAME"in prosper location,
<br /> 3. Check the appropriate box for°I YPE OF BUSIItI;SS E.) F ERSFIIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4: Check the appropriate box for TYPE OF BUSINESS, -
<br /> 5 If ff acili y/Site is located within an Indian reservation or other Indian trust lands,check the beast marked"YES".
<br /> 6. Indicate the NUMBER ofTANKS at this rSII'E:'
<br /> 7. Record the E3,PA,ID 4 or write".NONE"in the space providrld.-
<br /> IZ PI'OI'I:I2TY COWL R IN71'OR sIA'171.O 4 A!)I)RESS(MI,3 T 131 C:OMPLI.'TED)
<br /> Complete all items in this section,unless all items are the same as SECTION I;If the ssarne,write"SAMI AS SITE`across this serrata: Be sure
<br /> to check PROPERTY C}WNERSIM TYCalilaox:
<br /> ITT.TANK OWNER INFORMATION&ADDRESS(M ST BE C ONIP.;l~`IED)
<br /> Complete all items ill this section,sinless all items are the saute as SEC'FI0N I;If the sante,write"SAME'AS SITE"across this section. Be sure
<br /> to check"S:h°SIC OWNERSTYPE,box.
<br /> Ik'.BOARD 01'EQUAI.IZATION UST Sl`i3R AGE I•`EE ACCOUNTNUMBER(MUST BF',CC7;V(4'J,, EDi SIC AR11F,CLI,;a,CHAVITR 6'75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE,.)
<br /> Enter your Board of l.tt ta.ic afion{13C?h)CST Storage fec,i coons number which is required tx fore your l,x nit afsllhc,",r.n call be pzwr'e>se,!
<br /> Re gistunioa e�:th the B01 wit_„r:gearc that you will receive a clnaacrly storage fee return in rcpolting the SEI.0%(t lni sl ftrr Ia.E,At f.e<iue on the
<br /> nurnbe.r of gallons placed ill your,US Vs, 'I1.c 1301;will axle:p°zsons exempt frorn paying th v storage ice so,,.t;r -'s ;, d ;ry .ll., 'ifs ,M,<,.,ergs
<br /> n.ati a.:.eci account a.,trr,bur'with the 13f>TF or i.'you haveany ,uesci<`,ns o f ung lite ,f�^c:or excrnptie sa ,ilia as„c aci est,,st'a:.,l 91. 3�. ,<fr=z.i.rite
<br /> ;
<br /> to the 801"',at the ,:g�s 10.[0+. ad<?r,ss Board of Isg€a.al.ratauYz,Tau€:I I'axcx Division,11.0.Box 9,1�5 ?.Swt.r,as...rrto,CA 111�- )C rnl?.
<br /> V, 1'I'I I OLIF.UM US`i°FIN ANC:IAL RESPONSIBILITY t,M ST BI,COMPIs}1ED FOR PLITROLIP 'I US Fs ONLY,S!,I SEC]It.r.s.>2711 ,a)(`)
<br /> O 1 11:Y 23,C.l I AP7I.R 16,CALIFORNIA CODE,01,REGI LA l LONS,) '
<br /> Irt s-eafy Lac,nierhod,, )ussd by the owner andlor"opc ratcsr,in rineting the,Federal and Suite,finanwral>c.qp ,ib r�wy i.STs by
<br /> any Federal of State agency as vcll a,non-petrolourn US`I`s care exempt from this requirement. �
<br /> VI.LEGAL N01ll rCATION AND FT11,11NOY ADDRESS
<br /> Check ON F BOX for the;addtcss that Ali[bc:used for S3C3TH LEGAL A°:DB1.LLlNG.NOTlt'(C,kIONS.
<br /> TANK(l`}4NER OR AU'FIl0i�It.I I i IAF I'R SJ'iN'I'A I"IVE,mus,r SIGN AND DATEI'll!"FORM AS INDICATED, r,SEI S'l.0:1O fir 27 1
<br /> (ra)(13)€3F TI' LE,23 CITAI'l illi 16,CALIFORNIA CODE OF RE.GUL.A'I IONS,i
<br /> €RSTRUC VIOLA I°C311 Ti1F LOCAL AGENCIES
<br /> The county:an jurisdiction ttufnlx;rs are predetermined and curl be obtained by calling the Sate:I3c atki(916)227 4.1(03, ,h ,a:.rl,t;i�trinlicr naay Nx
<br /> ;�,
<br /> assigncd by the local ancy;ho evs;r,this€tram r rn is be numerical said cannot contain any alphabefi al chaaracacrs, If local pre c.rs
<br /> the State Board to assign the fatality number,please leave it blank.
<br /> IT IS THE RESPONSTBILF"T'Y OF T IIIc LOCAL AGENCY THATINSPECTS THE FACILITY TO VERIFY THE ACCURACY OF"EIIF
<br /> INFOItMAT1O.N, THIS APPLICATION CANNOT BEz.PROCESSED IF THE BOE ACCC)UNT,KUNA1E311R IS la OT FIl,:fLE'D IN, Till l-0C'AL
<br /> AGENCY IS RIeTiI'ONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INI°C)I'�A4IATION BOX AttiI3FOR
<br /> FORWARDING ONE,FORM`A"AND ASSO LATFD FORM."I3"(s)TO TIIIa FOLLOWLNG ADDRI:;SS.^"I HE LOCAL AGEUNCY SHOULD
<br /> RETAIN;;I IIS:ORIGINAI S AItiI7IaC112WA;RD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD Iii;
<br /> RETAINED AINED BY T13E,TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE"WATER RESOURCES CONTROL BOARD
<br /> C/O S. ,E.E.P.S,
<br /> DATA.PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARr�h�O TAT„CA 90723
<br /> &93 FORO 1MR1
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