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INSTRUCTIONS FOR COMPLETING F0P,,M "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OFTITLE 23.CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND-45289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REOUIRE OWNERS TO APPLY FOR AN UST OPERATING PERN,11T,
<br /> 1, One FORM"A`°shall be completed for all NEW PERMIT CHANGES 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 PERMIT APPLICANT or the:LOCAL AGENCY UNDERGROUND TANK INSPECTOR,
<br /> 4. Please type or prinrclearly all requested information.
<br /> 5. Use u had point writing instrument,you are making 3 copies.
<br /> 6. Tank owner must submit a facility plot plan to the iocal agency as`part of the application showing the location of the IiSTs with respect to
<br /> buildings and landmarks[Section 2711(a)(8),CCRJ.
<br /> 7. Tank ownermust 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)(11),CCR).
<br /> TOP OF FORD:"MARK ONLY ONE ITENT'
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> L. Pr CiLITY/SIT'E'INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> I. 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.SOX 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"SAINTE"in groper location.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4,, heck the appropriate box for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is locaied'within an Indiana rese€vation or other Indiana trust lands,check the box marked"`CES",
<br /> 6. Indicate the NUMBER of TANKS at this SITE,
<br /> 7. Record the E.P.A.ID#oe write"DONE"in the space provided.
<br /> 11. PROPERTY OWNER INFORMATION&ADDRESS(MUST RE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1;If the same,write"SAME AS SITE"azross this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> 111.TANK OWNER INFORMATION Lti ADDRESS(MUST BE CONIPLET ED)
<br /> Complete all items in this section.unless all,items are thesame as SECTION 1;If the same,write"SAME AS SITE"across this skctioat. 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 6.75,'
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY COTE.) -
<br /> nter your Board of Equalization(BOE)UST storage fee;recount number which is required before your permit application can be processed,
<br /> Registration with the BOB will ensure that you will receive a quarterly storage fee return in reporting the per gallein fee due on the another of
<br /> gallons placed in your LSTs. The BOE will code persons exempt'from playing the storage fee so returns will not be sent. If you dei not have-an -
<br /> account number with the BOE or if you have any questions regarding the fee or exemptions,please call the BOB at 916-322-9669 or write to the
<br /> BOE at the following address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0001,
<br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (ta)(l 1)
<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 regtlirdments.USTs owned by
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement.
<br /> VI,LEGAL NO`I FICATION ANIS BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZF-D REPRESENTATIVE MUST SIGN ANIS DATE THE FORM AS INDICATED. [SEE SECTIONS 2711
<br /> (a)(13)OF TITLE.23 CHAPTER 16,CALIFORNIA COTE 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)227-4303, 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 VENFY THE ACCURACY OF THE
<br /> INFORMATION, THIS APPLICATION CANNOT"BE PROCESSED IF THE BOE ACCOUNT NUMBER IS'NbT°FILLED IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE CORTPLETIole° OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL .
<br /> AGENCY SHOULD RETAIN THE ORIGINAL'AND"YELLOW COPIES. THE PINK COPY SHOULDE- AI D BY THE TANK
<br /> OWNER,
<br /> 6. 5
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