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INSTRUCTIONS FOR COMPLETING "
<br /> GENERAL INSTRUCTIONS,
<br /> SECTION 2711 OF TITLE 2.3 CTd APTR I&C LIFOR IA CODE OF REGULATIONS AND SECTIONS 252n6.25257,AND 25289 OF CHAPTER
<br /> 63,DIVISION 20,CALIFORNIA IIEALT I AND SAI '.TY CODE REQUIRE OWNERS TO APPLY FOR AN CJS`["OPERATING PERMIT.
<br /> I. Ore FORM"A"shad be completed for all NEW PERMIT CANG Sor any FACILITY/sITE FACILITY/s€7` INFORMATION C;IIANGY S.
<br /> 2. St iBMIT ONl._Y ONE(I)FORM"A"for+a I°acilitytSite,regardless of the nurnber of tanks located at the site.
<br /> 3. '[`lois form should be completed isy either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. please type or print clearlyall requested sted informatio .
<br /> 5. Use a hard point writing instrument,you are making 3 eotoes,
<br /> 6. Tank owner must submit it facility[slot plan to the local agency as kart of the application showis€.the lo=tion of the d.<STs with respect to
<br /> uildbigg*s and land arks[Section 2-7 11(a)(S),CCRI.
<br /> 7. Tank owner[trust 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)(]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 /> I, Record mune and address(physical location)of the underground tank(s),
<br /> NOTE: Address MUST haven valid physical location including city,state"mid zip code.:
<br /> P,O.BOX NUMBERS ARE NOT ACCEPTABLE,
<br /> Include nearest cross streetand name of the operator,
<br /> 2. Phone number must have an area cone. Ifthe night,number is the same,write'SA MB"in proper 1€crttion,
<br /> 1 Check the appropriate box for TYPE Of BUSINESS OWNERS141P(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4, Check the appropriate box for TYPE OF BUSINESS.
<br /> 5. If racility/Site is located within an Indian reservation or other Indian trust lands,check the box marked"YES`
<br /> 6. Indicatt,ifi NUMBER of TANKS at this SITE.
<br /> 7. Record rhe E.P,A.ID#car w=rite"NONE"in the space provided,
<br /> TI; PROPERTY OWNER INFORMATION&ADDRESS(MUIST° ECC3MPL.ETED)
<br /> Complete all items in this section,unless all items ore the sonless,SECTION 1;if the same,write'SAME AS SIT["azcross this section, Be stare
<br /> to check PROPERTY OWNERSHIP'I TYPE box,
<br /> 111,TANK OWNER INFORMA 110N&ADDRESS(MUST BE COMPLETED)
<br /> Complete alt items in this section,unless tall items arc the Sanas.as SECTION 1;If the sarne,write
<br /> "SAME AS SITE"across thi; flection. 'Be sure
<br /> T
<br /> to ch ck TANK OWNERS TYPE box.
<br /> IV,BOARD OF EQUALIZATION ION USST STORAGE:I'EE ACCOONT NUM[ ER(MUST BE COMPLETE-D.SEE ARTICLE 5,CHAPTER 6,75,
<br /> DIVISION 20.CALIFORNIA HEALTH AND SAFETY CODE.)
<br /> )
<br /> Enter your Board of Equalization(130E)US'T,=ra e fee account number which is required before'your permit application can be proeesse&
<br /> Registration with the BOB will ensure that you will ra cc iv e a quarterly;storage fee return in reporting the per gallon Ive due on the number,of
<br /> gallons placed in your USTs, The BOB will code persons exempt from paying the storage fee so returns witl not he sesta€. If lyOu do not have ars
<br /> account number with the BOB or if,you base an,questions regarding the fee or exemptions.please call the BOEat 916-322-9669 or write to the
<br /> BOBat the following address Board of Equalization,File]Taxes Division,P,O,Box 942879,Sacramento,CA 94279-00,01,
<br /> V. PETROLEUM USI"FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM CST-ONLY,SEE SECTIONS 2711 (ar)(I 1) ,
<br /> PTT T I TL.E 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,)
<br /> Identify the rtiethod(s)used by the ownerand/or operator,in n€sting the Federal and strati:financial l msponsihihty r.tl aireraaeni.,,UST°s owned by
<br /> any Federal or State agency as well as noxi-petroleum US"Ts are exempt front this requirement.
<br /> 1.LEGAL NOTIFICATION ION AND BILLING ADDRESS
<br /> Check ONE BO for the address that will be used for'BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATT IVE I'AUS I".`"SIGN AND DATETHE FORM AS INDICATED. [SEE SEC.TIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.]
<br /> I sT RUC CION FOR THE LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)'„?27-430 . The facility number may
<br /> be;assigned by the local agency.however,this number must be numerical and cannot containany alphabetical characters. If the local agency
<br /> prefer the State Board to assign the facility number,please Dave it blank.
<br /> IT IS THE RESPONSIBILITY'OF THE LOCAL ,AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORNTATION, THIS APPLICATION CANNOT BE PROCESSED IF T14E BOET14 ACCOUNr NUMBE IS NOT I"ILL.FI)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 AND YET-LOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
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