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INSTRUCTIONS FOR COMPUTING FORM "A" GENERAL INSTRUCTIONS: SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF;REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT. 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/STYE INFORMATION CHANGES. 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located.at the site. 1 This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 4. Please type or print alearly*krcquested Wormation: 5. Use a hard point wilting instturrierit,you8re making 3 copies. 6.'Tank owner must submit a facility plot plan to the local agency as pan of the application showing the location of the USTs with respect to buildings and landmarks[Section 2711(a)(8),CCRL \'_. - - 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the applicationf'or petroleum USTs[Section4711(a)(11),CCR]. TOP OF FORM:"MARK ONLY ONE ITEM" Mark an(X)in the box next to the item that best describes the reason the form is being completed, I. FACILITY/SITE INFORMATION&ADDRESS(2MUST BE COMPLETED) 1. Record name and adflress(physical,location)of the underground tank(s). NOTE:Addres&MOST hive a valid,physicai loeation incl tding,city,state,and zip code. P.O.BOX NUMBERS ARE NOT ACCEPTABLE. Include nearest cross street and name of the operator. 2. Phone number must have an area code. If the night number is the same,write"SAME"in proper location. 3. Check the appropriate box fpr�TYPE'OF„,BUSINESS O�VItiERSHIP(ex.CORPORATION,INDIVIDUAL,etc.). 4. Check the appropn`ate box for TYPE OF BUSINESS. 5. If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box marked"YES". 6. Indicate the NUMBER of TANKS at this SITE.- 7. ITE.7. Record the E.P.A.ID#or write"NONE"in the space provided. U. PROPERTY OWNER INFORMATION&ADDRESS(MUST.BE COMPLETED) Complete all items in this section,unless all items are the same as SECTION 1;If the same,write"SAME.AS STTE”across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED) •Complete all items in this section,unless all items are the same as SECTION l:If the same,write"SAME AS SI°ITE"across this section. Be sure to check TANK OWNERS'l'XPE box., IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CIIAPTIER 6,75, DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE.) Enter your Board of Equalization(BOE)UST storage fee account.number which is required before your pennit applicat.ign Cain be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee rctum in reporting the$0.W6(6n)ills)icer gallon fee due on the number of 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 account number with the BOE or if you have any questions regarding the fee or exemptions,please caI.l the 1101E at 916-322-9669 or write to the BOLE at the following address Board of Equalization,Fuel Taxes Division,P.O.Box 912$79,Sacramento,CA 91279-0001. V. PETROLEUM UST ITNANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLI:iUM USTs ONLY,SIEIE SIEC'l IONS 2711(a)(8) OF TITI.,E 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.) Identify the metltod(s)used by the owner and/or operator,in meeting the Federal and State financial responsibility requirenit nts.UST's owned by any Federal or State agency as well as non-petrolcurn USTs are exempt from this requirement. VI.LEGAL NOTIFICATION AND;BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS. TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FOR_I AS INDICATED. [SLE SIEC:TIONS 2711 (a)(13)OF'1TTLE 23 CI IAYI'ER 16,CALIFORNIA CODE OF REGULATIONS.) INSTRUCTION FOR THE LOCAL.AGENCIES The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board`(916)227-4303. T'he facility number may be assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the local agency prefers the StatwBoard to assign the facility number,please leave it blank. IT IS THE' RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE INFORINIATION. TII1S APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING O gTORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD. RETAIN* 'fit ORidNALS AND FORWARD THE YELLOW COPIES TO-THE FOLLOWINGS ADDRESS.THE PINK COPY SHOULD BE RETALNIED BY THE TANK OWNER. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O S.W.E.E.P.S. DATA PROCESSING CENTER P.O.BOX 527 PARAMOUNT,CA 90723 ags FORD12DRI