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INSTR IONS FOR COMPLETING F y I e'A�,
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 2;286,252£17,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN LIST OPERATING PERMIT,
<br /> I. One FORM"A"shall tie conavI,tend for All NEW PERN41T CHANGES or any FACILITYISITE INFORMATION CHANGES.
<br /> 2, SUBMIT ONLY ONE F6P "A" a 7 c�xtv6c,regardless of the number of tanks? ,„ st at:'ho site.
<br /> 3. This form should be cote c.i uy e,t,..; PERM['t',�F'PLICANT or the LOCAL AGENL x I'?SDERGROUND TANK INSPECTOR,
<br /> 4, Please type or print clearly all n caucste 41
<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 LISTS with respect to
<br /> buildings and landmarks(Section 2711(a)(8),CCR]-
<br /> 7. Tani:owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part ofthe
<br /> application for petroleum USTs[Section 2711(a)(]1),CCR].
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> 1. FACILITYISITE 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,stats:.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 must have an area code. If the night 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 /> S. If Facility/Site 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 /> IL PROPERTY OWNER INFORMATION&ADDRESS(MUST BE 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 cheek PROPERTY OWNERSHIP TYPE box.
<br /> 111.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are thesame 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 EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 5.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your Board of Equalization(BOE)UST storage fee account number which is required before your permit application can be processed.
<br /> Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the per gallon fee due on the number of
<br /> 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
<br /> account number with the BOE or if you have any questions regarding the fee or exemptions,please call the BOE at 916-322-9669 or write to the
<br /> BOE at the following address Board of Equalization,Fuel Taxes Division,RO,Box 942879,Sacramento,CA 94279-0001,
<br /> V. PETROLEUM LIST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR.PETROLEUM USTs ONLY,SEE SECTIONS 2711 (at)(I t)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the method(s)used by the owner and/or operator,in meeting the Federal and State financial responsibility requirements.USTs owned by
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. [SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA COBE OF REGULATIONS.]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State:Board(916)227-43£13. The facility number may
<br /> be assigned by the local agency-,however,this number must be numerical and cannot contain any alphabetical characters. If the local agency
<br /> prefers the State Board to assign the facility number,please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF TIME
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE"LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL ANIS YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER.
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