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INSTRUCTIONS0
<br /> "A"
<br /> GENFRAL INSTRUCTIONS:
<br /> SECTION 2711 OF'IITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS"_5286,25287,AND 25259 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> I. One FORM"A"shall be completed for all NEW PERMIT CHANGES or anyFACILITY/SITE INFORMATION CHANGES,
<br /> 2, SUBMIT ONLY ONE(])'FORM"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This forth should he completed by either the.PERMIT APPLICANT or the.LOCAL AGENCY L,tNDERG OLNI3 TANK INSPECTOR,
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use as 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€hc applications €s iarg the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(5),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 petroleum USTs[Section 2711(a)(11),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 ffcarm is being crunpleted.
<br /> L. FACILITY/SITE 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,state,and zip code.
<br /> P.O.BOX NUMBERS ARE NOT ACCEPTABLE.
<br /> include nearest cross street and mine of the operator.
<br /> 2. Phone member must have an area code. If the night number is the same,write"SAME'in'proper location.
<br /> 3. Check the appropriate box forT'YPE OF BUSINESS OWNERSHIP(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,chock the box marked"YES".
<br /> 6, Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E,P_A.ID#or visite"NONE"in the space provided,
<br /> II. PROPERTY OWNER INF-ORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1;If the carne,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> 111.TANK OWNER,INFORMATION c&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 TANK.OWNERS TYPE box.
<br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(TRUST BE COMPLETED,SEE ARTICLE 5,CHAPTER 6.7-5,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE,) _
<br /> Enter your Board of Equalization(BOE)UST stowage 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 praying the storage fee so returns will not be sent. If you do not haveart
<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 /> BOB at the following address Board of Equalization,Forel Taxes Division,RO,Box 942879,Sacramento,CA 94279-0001,
<br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (a)(I1)
<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 NOTIFICATI€)NS,
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND LATE THE FORM AS INDICATED, [SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,I
<br /> INSTRUCTION FOR THE LOCAL.AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-43I13, The facility number may
<br /> be assigned by the focal agency;however,this number roust 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 THE
<br /> INFOR LIA,g ION,. THIS APPLICATION CANNOT BE PROCESSED IF THE BOB ACCOUNT NUMBER IS NOT Fl$LEf3 IN. 'FHE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE FOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAIN BY-THE TANK
<br /> t?w3 N €2.
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