|
INSTRUCTIONS FOR COMPLETING FORM "All
<br /> GENERAL INSTRUCTIONS-
<br /> SIC TION 2711 Of`-I-lTI.,E23,CIIAPTI-,R 16,CALIFORNIA CODE OPREGULATIONS AND SECT IONS 25256,25287,.AND 252$9 OFCHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PER.
<br /> I. One FORM"A"shall be conifilcted for all NEW PERMIVI'CII ANGES or any FACU-,I'rY,'/SITE INFORMATION CHANGES,
<br /> 1 SUBNMITONLY ONE(1)FORNI"A"for a Facility{Site-,regardless of the number of ranks located at the site.
<br /> 3. This feral should be completed by either the PERMIT'APPLICANT or the LOCAL AGENCY UNDERGROUND TAIKK INSPE'CFOR.
<br /> 4. Please type:or print clearly all requested infornortion,
<br /> 5. Use a h4rdfimot writine ho-muncllt,you
<br /> 6. Tank owner must submit a facility plot plan to,the local agcncy as part of the application showing the location of the US'Fs with respect to
<br /> buildings and landmarks[Section 277 11 (a)(8),CCR),
<br /> 7, Tank owner must subinit ocurn Cation showing compliance-,kith state financial responsibility requirernereli to the oeal ageticy as part of the
<br /> unn USTs 'oil.2711(a)(I 1),Ct,,�'Rj.
<br /> applicati%tr for pcirtsIg s[Secu
<br /> TOP OF FORM:"NIARK ONLY ONE ITENT'
<br /> ,Mark an(X)in the box next to die itern that best describes the reason the forns is being completed,
<br /> I. FACILITY1511'E INFOR]tIATION&ADDRESS(MUST13p,COMPLETED)
<br /> 1, Record name and address(Physical location)of the underground tank(s).
<br /> NOTE. Address MUST hat
<br /> a valA physicaj htcalion inchnfing city,state,and zip code,
<br /> P.O.BOXNUMBERS ARE INOT ACCT S'
<br /> Include nearest cross street and roune of tile operaton
<br /> 2. Phone number must have an area code, If the night number is the same,write"SAME"lit proper location.
<br /> 3. Check she appropriate box far TYPI,,,OFBUSINESS OWNERSHIP(ex.,CORPOAATION,INDL VIDUAL,etc,).
<br /> 4, Check the appropriate box for TYPE OF BUSINESS.
<br /> 5, If check t4c box marked"YES".
<br /> 6. Indicate the NUNIBER,of I ANKS aLdilis SITE,
<br /> T Record the E,P:A,11)#or write"NONE"'in the space Provided,
<br /> IF ICRC[Il,'I"l'YOWNERI.NOR.N4A'I'IC)N&ADDRESS(MtI'ST]SII COMPLETED)
<br /> Complete all ilenis in this Section,in-Jess all items are lhesanie as SEC]'ION Ljf the settle.,aerlteAME AS SITE—acroslthic stc�lion, Be sure
<br /> to checla PROPEKI'Y OW NERSI 11HITY11F box,
<br /> IILTANK OWNER INFORMATION&ADDRESS(MUSTBE COaIPLE-11�,D)
<br /> con"PIcte,all iterna in this section,unless all oerns are the same as SECTION I If the same,write"SAkIE AS SITE"across this secfiean?Be-,ure
<br /> ll,- wb4ck,TANK(AkrN
<br /> IV.BOARD 0l`EQI1-AI1ZATR)N UST SIFORAGif, ACCOTJ-NT NUIMBE-R(MUSTBE,COMPLETED.SRI, ARTICLE 5,CIIAMTR6,75,
<br /> I)I,VISI(,)\20,CALIFORNIA III'AL-1-11 AND SAFETY CODE)
<br /> 0E)I
<br /> l: i i
<br /> ltcektraion w1,Ilic 11,01"will,t,"ure that you v,ill receive a quarterly storage fee wturn in iellorting the SWY)f)(bp'nills)pe!g.11oo fec&Ilc on thc
<br /> true)ter rtfgtfflont pla,:cdin your USTs. lbe I301,'ill c(ole Persons exen)pt front paying the,sloragc fcc so ;,I bo"ent, If Nt)a do not
<br /> have,an account the BOE or if you h1avo any questions regarding the fee or cxornpi)ons,ple'ast"caul 1h,B(A"a!()I("32,21-"'669 or e=lite
<br /> e IB
<br /> to tits' at tile foliovcit,g addircss Hood of Equalization,Fuel Taxes Division,P.0,Box 9428�9, CA 9,127Sl,000L
<br /> V. PIDROLEUIM UST 1ITNANCIA!, (MUST IIE COMP LE'll,'D FOR PE'l ROLEl USTs ONLY,SEE SEC,]ION'S 2711 (a)(8)
<br /> CIF TITI 1`23,("H API T"R 16,CALIFOR NIA CODE 01,BE'OULATION&)
<br /> Identify nterneth(xi(s)uscd by the o"'nerandlor opclatc-,r,in ntoeting tile Federal told State,finani,ial rosy risibility 1-:STS z xn3 ,d h�
<br /> any ied,,ralorStao,agency as w=ell as neon-petrolcual USTs arc exempt Crow this rcqLJrcntcnt—
<br /> VI.LEGAL NO]111CATION AND BILLIN(3 ADDRESS
<br /> Check ONE BOX for this address that tvill be used for BOTH LEGAL AND BILLES(.3 NOTIFICATION&
<br /> TANK OWNER OR AUTHORIZED RE'PRESENTATIVE MUST SIGN AND DATETHE FORM AS INDICA ITelt. ISEI-SFIC-3-IONS 2711
<br /> (a)(13)OF TITLE,23 CI1AP`IISI 16,CALIFOR'NIA CODE OFREGULAT10'.NS.1
<br /> INSIRUCTION FORT111",LOCAL AGENCIES
<br /> The county anjulisdiclion numbers are predract-mined and can be obtained by calling the,State.Board(1916)227-4303, Shwa'--cil'Ov notuber miv be
<br /> assigned by the local Agency;hovever,this number ninst be nurnefiral and cannot contain any alphabeiical characters� If the,local agency lm"'jers
<br /> the Stala&.Board to a��ign thk�facility monger,please leave it blank.
<br /> IT IS TIll,' RESPONSIBILITY OFTHE LOCAL AGLINCYTHAT INSPECTS THE FACILITY TO VERIFY THE, ACCURACY OF'111E
<br /> LNFORNIATION. THIS APPLICATION CANNOT BE PROCESSED IF TITS BOE,ACCOUNT NUMBER,IS NOT FILLED IN, TIll Lk)CAL
<br /> AGE'NC'Y IS RF'SPONSIBLE FOR THE COMPLE,TION OF THE "LOCAL AGENCY USE ONLY" INFORMATION 13OX AND FOR
<br /> FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TOTHE FOLLOWING ADDRESS, THE LOCAL AGENCY SHOULD
<br /> RETAINI Ill, ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWLNG ADDRESS. 11E PINK COPY SHOULD BE
<br /> RE.TAINED 13Y THETAINK OWNER.
<br /> $TATEOFCALIFORNTA
<br /> STATE WATLA-RE-,$OURCES CONTROL BOARD
<br /> e C/O S.W.L.E.P.S
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 193 FORDmRi
<br /> 1p
<br />
|