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<br /> INSTRUMONS FOR COMPLETING FO' "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS T40,APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITYISITE DMORMATION 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 cmnplewd by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4. Please type or print clearly all requested 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 part of the applicatrott 4uowtng die location of the USTs with respect to
<br /> buildings and landmarks(Section 2711 (a)(8),CCRI.
<br /> 7. Tank owner must submit documtantation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2711(a)(1.1),CCRI.
<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 fort is being completed
<br /> 1. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name and address(physical location)of the underground tank($).
<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 name of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same,write"SAME"inproper toeatton,
<br /> 3. Check the appropriate box for TYPE OF BUSINESS—OWNERSHIP(ex.CORPORATION., QAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indiantrustlands,checlatimbox maikid"YES".
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E.P.A.ID 0 or write"NONE"in the space provided.
<br /> H. PR.OPEI2T'Y OWNER INFORMATION&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 suit
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> III.TANK OWNER ILNFORMATION&AI.)DRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1;If the sante,*trite"SAME AS SITE"across this section. Be sure
<br /> to check TANK OWNERS TYPE box.
<br /> IV.130ARD OF EQUAI.IZ.ATION USTSTORAGE FEE:ACCOUNT NUMBER(MUST BE GOVIPLE'l EU.SEE ARTI.CLH 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA I113-AL:i'll AND SAFETY CODE.)
<br /> Enter your Board of Equalization(130E)USTstorage fee account number which is required bef-)ie your permit aMicat.ion can be processed.
<br /> Rc f,istrati.>n witty the BOIi will ensure that you will receive a quarterly storage,fee retttr' t',', �itlg the,50.tx)t'r spills)per gallon fee due on the
<br /> number of gallons placed in your USTs. 'Ilse 1301;will code persons exempt from paying the storage ke so returns will not be sent. If you do not
<br /> have an acwunt number with the 130 or if you have any questions regarding the fee or examptigis;please call the BBI'at 916-322-966()or write
<br /> to the 13013 at tho following address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,:Sacrainento,CA 9•1279 0001.
<br /> V. PETROLEUM LISTFINANCIAL R1.:S110NSIBII_ITY(MUST BE COMPLETED FORYETROLf UM USTs ONLY,SEE.SECT IONS 2711(a)(8)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF RIi(;ULATTONS.)
<br /> Identify the method(s)used by the owner and/or operator,in meeting the Federal and State financial responsibiliry requireutcttts.USTs owii-ed by
<br /> any Federal or State agency as%yell as non-Ix trolcurn LSTs are exemptfrom this.reguirement .
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check.ONE.I3OX for the address that will be used for BOTH LEGAL AND BILLING INTOT1IICATTONS,
<br /> TANK OWNER OR AUTHORIZED REPRES1EtNTATIVE M['STSIGN AND DATE Tilt FORM AS INDICAT'EI?. ISEE SEicriONS 2711
<br /> (a)(13)OF TITLE 23 CIIAI-I-ER 16,CALIFORNIA CODI>O"REGULATIONS.)
<br /> INSTRUCITON FOR TI IE LOCAL AGENCIES
<br /> The county an jurisdiction numbers are predetermined and can be obtained by calling the State,Board(916)227-4303. The facility numt r may be
<br /> assign_d by the local agenev;however,this number must be numerical:and cannot contain any alphabeticii characters. If the local agency prefers
<br /> the State Board to assign the fatuity number,please leave it blank.
<br /> IT IS THE RLSPONSIBILITY OF TIIE LOCAL AGENCY THAT INSPEeTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE'BOir ACCOUNT•NUMBER IS NOT FILLED IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE FORK["A"AND ASSOCIATED FORM"B"(s)TO,THE FOLWWV-,*ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN TIIE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRFSS.THE PINK COPY SHOULD BE
<br /> RETAINED BY THE TANK OWNER.
<br /> ST,pTE OF CALIFORNIA
<br /> STATE-WATER RESOURCES CONTROL BOARD
<br /> C/O S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3.,93 _. fCIROiM11111
<br />
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