|
INSTRUICTIONS FOR COMPLETING FORM "Ati
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 271 T OF TITLE23,CHAPTER t€,CA iFf.)E NIA C:;ODE OF REGULATIONS AND SECTIONS NS.55 867,,.�ND OF CHAPTER
<br /> ,6,7,DIVISION 20,CALIFORNIA HEAL,.II AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR, AN I.,` ' OPERA sly,.a'ERNMI-n
<br /> I, Ore FORM"A"shell be cc.mpic;ied fmr 0 N W TIERMT CHANGES or any FACILITY/SITE INI~C:)RMA ION CHANGES,
<br /> 2. SI_BBI I°ONLY ONE(I)FORM'A"fora, Facilhv/Siteq regardless of the nurnber of tanks located at the site.
<br /> 3, This Corny should be €aaaapla tcd by either aie'PE RMIT rs PPIAC ANT or the LOCAL.AGENCY UNDERGROUND TANKXNSE EC"I )R,
<br /> 4 Please type or print clenrly rail requested ani orratatatan.
<br /> 5- T se a hand point writin,,-haste lament,you lira ttaakirrt s copicas.
<br /> 6, Tank oowncr must submit a facilit nhot plan to the local agency a's pall of the application s,oiviaag the location n('tta°111SIs s 3;ith syspe t to
<br /> buildinSs and landmarks[Section'2"J I(a)(Sj,CCR],
<br /> 7, Tank ownc;r trrasst submit docurnc n ation showing compliance with state fn aaraciad responsibility requirements to the ha!ag carcy as Part of the
<br /> application for petroleum USTs[Section 27 11 a_(7 1),CC RJ,
<br /> FOR OF FO R xT:"IM ARK ONLY ONE IT ENI"
<br /> Mark an(X)in the box next to the itarta that best describes the r €vlorl<,ac feam is beim con'tpleted.
<br /> L FACILITY/SITE INFORMATION&ADDRESS DESS(NIt S T"BE COMPLETE[))
<br /> T. Record mine and address(physical location)of the underuound€rark(s),
<br /> NOTE: Address Mt'i ST"ha€ve a valid physical locatrnn ba.hAd n,-City,si,a ,and zip saute,
<br /> P,O,BOX NUMBERS ARE NOT ACCEPTABLE,
<br /> Include nearest cross stmt and name of the aperstor.
<br /> 2, Phone number must nine an area code, if the night number f 9 the,same,writa "S As E`m proper location,
<br /> 3. Check glee appropriate box for TYPE OF BUSINESS OWNERSHIP(ex,CO7Ro R ATIoN,INDIA IDUT AL,etc,).
<br /> 4. Check the appropriate bim fol-TY E OF BLSINESS,
<br /> 5, If F°acilitvfSite is Ideated within ars Indian r.�zr,,,inion or rather Indian trnr t lands,cheek the box marked"'YES",
<br /> d. Indicate the NL MBER of TANKS at this SITE
<br /> 7- Record the EE,P,A.ID 4 or write"NON"E"In the spares,provided.
<br /> II, PROPERTY OWNER INFORMATION,&-ADDRESS(INTU'S I`BE C'OMPLF`I.1 I))
<br /> €.;ompl rte sill kerns in this section,unless all items are the aan.e as SECTI€)N i;If the saamc-write"SAME AS ST'TEE'a.cmss this.vct7cnl, Be Savo
<br /> to check PROPERTY OWNERS i I I PT PE box,
<br /> ITI.TANK OWNER INFORMATION ATION&:ADDRESS(MUST BE CON't'EwE-E.1.7
<br /> Completeall aeras in this:_cution,unless call reals are;the same as SECTION 1 If the sarne: wliie"S.AiME AS SITE"across this st.cti(sn. Be sure
<br /> tri ch e c,k i;Ali K 0WNFRS TYo E:,:,ax.
<br /> IV,BOARD OFEQUAL IZATIO N DIST;STORAa.EFILE CCI_SWLLTED SEE.Aa 1ICILE 5,CHAPTERt5.7 ,
<br /> DIVISION-20,CALIFORNIA ITE ALTH AND SAFETY CODE-)
<br /> Enter ycaa,ar Boald,of E qualiza on(BOE)LSI',-a ra e ice cacaxaunt nur bcr which is rcouhed before your pern it a plic:,f ien can ba pr z esscd.
<br /> Rcxi,atrsttion with the-SO h'i't e antra iiia,you will receive a ipelit'-dy sto"a€„e foe lerarn ill r"Porzing th y� fe
<br /> r galtou e due on the number ofgallons placed in your t e T:, The BOE will code perams exempt from paying the storage fee so returns will not lac&,,nt. Tf t ou do not have an
<br /> account number with the BOB or i "Tari have llnv quos tmns regarding the fee or exemptions,please cal the BOF;a!Eb,l6 or write to the
<br /> BOE=at the fol acid.<3ddcf ,,�Ballo:d of E quaali Pattion.I ue]"1`atx,,Division,RO,Box&f;2i 7f), acmn,mnl.;,CA 942'79-1001ll,
<br /> L', PETRO UNI IST FINANCIAL RESPONSIBILITY(IUST BE COMPLE TEI)FOR PETROLEUM LSTs ONLY,SSE.,SE T IPONS'2 11 (as){I I
<br /> OF TITI E 23,€"H sF EIR 16,,CALIFORNIA,`,ODE OF REGULATIONS,)
<br /> Identify the method(s)used by the owner and Or oT I-MVN',in meeting tile,Federal and Strate financial responsibility retl.,tare nemrs, : Ts owned 1w
<br /> any Fes ral tar Swle agency a wel:as non-petrolcufn USTs are e eatatst fail-an,this requircrne'ti,
<br /> VI,LEGAL NOT!F'TCATION'SAND I RILING ADDRESS
<br /> Check ONE B(')X,o,,the address ilial will be u:,,d for BOTH LEGAL,ATPD BILLING=NOTIFICATIONS.
<br /> TANK OWNER OR AL''I'ffOC EIRET:Y REPRI'SE;N'r A'I"IVEI MUSTSIGN AND D ATE THE tEtt:M AS INI LICA TT TT ,;SEF SIE'C'l IONS 2711
<br /> (a)O13)OF TTTI-E 23 CHARTER 16,CALIFORNIA CODE OF REGULATIONS]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county and jurisdiction numbers are pre&teruilred aged can he obtained by calling the State Board(9 16)227-4303 x c facility number may
<br /> Eye assigned by the local agency:however,this number nsust be rium rical and meanest contain any alphabetical characters_ l"the IcTal aterscy
<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 TIE FACILITY TO 1,11 FIFY "t HE, C"`S a RACY €7r FE
<br /> INFORMATION. THIS APPLICATION PION CANNOT I'BE PROCESSED IF THE BOB A C(AJNT ItitJMB IS NOTFILLED ILLED IN, 114E I oC AL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "Li)CAI. rA r USE ONLY" INFORMATION BOX, THE,LOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL, AND Y°ET..,F.-OW COPIES, THE PIN C)['Y' V-1—AlNED BY"I,FTE TAN
<br /> 6'95
<br />
|