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INSTRUCTIONS FOR COMPLETING FORM 't At'
<br /> GENERAL INSTRUCTIONS:
<br /> SECIFION 2711 OF IT LEL 23,CHAVIT,'R 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.71,DIVISION 20,CALIFORNIA IILAI:rl-I AND SAFETY CODE,REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all N LW PER MITCHANGES or any 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 PERMIT APPLICANT or the LOCAL ACT7,NCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please type or print clearly all reqLwacd 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 pan of the application showing the location of the USTg with respect to
<br /> buildings and landmarks[,Section 2711(a)(8),CCR].
<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 petiolcuru,USTs[Section 2711 (a)(I 1),CCRI,
<br /> TOP OF FORM:"MARK ONLY ONI'lTENV
<br /> Mark an(X)in the box iwxt to the iterin that best describes the reason the form is being cornplete&
<br /> I. FACIIJTY/,SI'I-L INFORMATION&ADDRESS(MUST BE CO'NIPLETT-M)
<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'NOTACCEP'I'ABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone rikiniber 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/Sitc,is located within an Indian reservation or Other Indian trust lards,check the box marked"YE
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the T-`T,A-ID 4 or write"NONF',"in the space provided,
<br /> TL PROPERTY OWNER INFORNIA11ON&ADDRESS(NIUS'I'BE,COMPI,I,,TT-.D)
<br /> Complete all items it)this section,uiJks%all iterni are the same.as Sl-',CTION 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNl�RSIIIIITYIIE.box.
<br /> 111,TANK OWNE"R IN11-'ORMATION&ADDRESS(MUSTBECOMPLETED)
<br /> Complete all items in this section,unless all items are the same as SEC 110N 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check-TANK OWNLRSTYPE box.
<br /> IV.BOARD OF EQUALIZATION UST STORA(31-FEL ACCOUNT NUMBER(MUST'BE COMPLETED.SEE ARTICLE 5,CTIAPTE.R 6.75,
<br /> DIVISION 20,CALIFORNIA lil"AL-I'll AND SAFETY CODE.)
<br /> I'lluct your lloaii,l of (BOE),UST storage fee account number which is required bt,,forc yourjx-mmt application cl,in be
<br /> R(sgi>llation i i1h rhe B()!i bill ol.slktc that Vol will Ficcivea quanurly sioiage fee relurn in reporting the SO.(X,)6(OIT111 ) gAlOfl f-1C dAe-On file
<br /> 'llic BOE will code persons exerlipthoty)paying the si'MAOC fcC W RIOMs nol},f, lfyojidonix
<br /> hasp, liulnbcr eaitkt 01t11 BOE or if You have any questions rCgardilIg the.fCQ OrONOMI)tIons,Utast:call th'B4O1, .at'910 322 9669 or write
<br /> to the BOL at the following adllitc�,Bouid,of Equalization,Fuel Taxes Division,P.O.Box 942979,S rax unerata,CA 91,279-0001
<br /> V.
<br /> OF
<br /> ,13,Ci 1APTER 16,CALIFORNIA CODE.01,RE'G l.:I.ATlONS,)
<br /> ldmtify the used by the(nncr and/Or('11-raLor,in-meeting the Federal and State fitrincial wsponsibili!y real-tin n. (snl,s.I.ST owwd by
<br /> any 1%,,dcl tdor St,tc.ar rcy as well as non-petroleum US I's are exciript from this requirement,
<br /> VI.LEGAL NOTIF"CATION AN 1)BILLING ADDRESS
<br /> Check ONF.'BOX for tete address that w;II be used for BOTH LEGAL AND BILLING.'NOTIFICA1 IONS.
<br /> TANK OWNER OR Al,"I'l 10RIZE11)REPR ESENTAI JVE'NIUSTSIGN AND DAI 1,THE"FORM AS LNDICA'l! D. ,SE F 1 F("TP)\,*S 2711
<br /> (a)(13)OF—I ITLF'23 CHAPTER 16,CAljlOIZN'IA CODE OF REGULATIONS.]
<br /> INSTRUCTION'FOR I III;LOCAL AG1`1NC11,1'S
<br /> The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board 916)227-4303, The facility nwrih;,.r may be
<br /> assign-cd by the local agency;howe'ver,this number TTIL6t be numerical and cannot contain any alphabetical characters. If the local agency prefers
<br /> the State Board to ass igyi the fiiciloy nurnber,please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY TIIAT INSPECTS "LITE FACILITY To vFRiry Tiff ACCURACY OF 111E
<br /> INFOR,\11A'!ION. '11115 APPI-ICATIO'N'CANNOT BE PROCESSED IF TIlL BOF,ACCOUNT NUMBER IS NOT FILLED IN, THE I.,OCAL
<br /> AGENCY Is KESPONSIBLE' FOR TlIE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION 13OX AND FOR
<br /> FORWARDIN'(3 ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN THE ORIGINALS AND FORWARD THE YELLOW COPIES TO 1`11E FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RI TAINE.'D BYT]IFTANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATLR RESOURCES CONTROL BOARD
<br /> C10 S.W.E.E,P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3193 FOR012OR1
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