|
INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SIEC:TION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 2.5289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALTFOR_\IA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1, One FORM"A"shall be completed for all NEW PERMITCHANGES or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2. SUBMIT ONLY ONE(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 PEIR. 1IT 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)(I1),CCRI
<br /> TOP OF FOWNI:"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that beast describes the reason the form is being completed.
<br /> I. FACILITYtSITE INFORMATION&ADDRESS(:,FUST 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 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 OWNERSI IIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box marked"YES".
<br /> 6. Indicate the NUMBER o€TANKS at this SITE.
<br /> 7. Record the E.P.A.11)4 or write"NONE"in the space provided.
<br /> II. 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 check PROPERTY OWN]RSFIIP TYPE.box.
<br /> III.TANK OWNER INFORMATION&ADDRESS(NIUST BE COrMPLE"PIED)
<br /> Complete all items in this section,unless all items are the same as SECTION I;If the same,write"SAME AS SII'IE"across this section. Be sure
<br /> to check TANK OWNERS TYPE box.
<br /> IV.BOARD 01-EQUAL.ILATiON US 1`SiOR GE 11:11'ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CIIAP`ITR.6.75,
<br /> DIVISION 20,CALIFORNIA Iil AL,TH AND SAFETY CODE.)
<br /> Enter your Board of Equal izaticm(1.I0r)UST storage fee account number which is required before your permit application can be pre+cesse(L
<br /> Registration ssill,,the BOE will;insure that you will receive a quarterly storage fee return in reporting the$0,0)6(6rttills)per gallon fee chic on the
<br /> number of gallons placed in your USTs. Tho 1301'will code persons exempt from paying the storage fee so reuArns will not be sent. If you do not
<br /> have an aeeoutu number with the BOE or if you have any questions regarding the fee or exemptions,plows call tiiw 1301i at 916 322-6669 err write;
<br /> to the BOE at the:following address Board of Equalization,Fuel Taxes Division,I1.0.Box 942879,Sacrarncnto,CA 9,1279-01001-
<br /> V.
<br /> 1279-01001_V. 1'I'13tOLE'.I:�l USTFI.NANC:IA!,iusPC7N,simi,TTY(mus-['BE COMr'LETED FOR PET1tOLEUM USTs ONLY,SEFSECI'IONS 2711 (a)(S)
<br /> 01�TI'TL F 23,CIIAVI`ER 16,CAI_:IORNIA CODE OF RE'GULA'TIONS.)
<br /> Identify the methal(s)used by the owner and/or operator,in meeting the Federal and State financial responsibility r.,�,r,,rort�_.at, USl's o%+red by
<br /> any Federal m State agency as well as non-petroleuttn USTs are exempt from this requirement,
<br /> VI.LEGAL NO[Ii ICAlION AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used fur BOTH LEGAL AND BTI.LINCs NO'I'1FICATIONS.
<br /> TANK OWNF R OR AI.TI1(.?Rl'I,I D RE.I'?tliSlviNTATIVE MUST SIGN AND DATE THE FORM, AS INDICATED.ED. (,`s::lE S1 C:'l IONS'2`11
<br /> (a)(13)OF'TiTLE 23 CIIAI1TFR 16,CALIFORNIA CODE OF REGULATIONS.]
<br /> INS*IIZUC`I'ION l°(}R'I'111 LOCAL,AGENCIES
<br /> The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility nunnber may be
<br /> assigned by the local agency;however,this number must be,numerical and cannot contain any alphabetical characters. If the local agency prefers
<br /> 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 THE
<br /> LNFOR-MATION. TIIIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED I.N.,'111E LOCAL
<br /> AGENCY IS RESPONSIBLE' FOR THE COMPLETION OF THE "LOCAL,AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDIN(T ONE"FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN']HE ORIGINALS AND FORWARD THE YELLOW COPIES TO THEFOLLOWINGADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BY THF.TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> CIO S.W.E.F,.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 40723
<br /> 3,93 FORD12DRI
<br /> •
<br />
|