|
INSTRUCTIONS
<br /> COMPLETING "A"
<br /> _ =
<br /> SECTION 2711 OF TITLE 23.CHAPTER 16,CALIFORNIA OF REGULATIONS,' .ND SECTIONS 252116,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY C4 -"E REQUIRE OWNERS DO APPLY FOR AN UST OPERATING PERMIT,
<br /> I. One FORM"A`shall be completed for all NEW PERMIT CHANGES or any FACILI'I YtSITE 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 print clearly all requested information.
<br /> 5. Use a hard point writing instea mint,goat are making 3 e ,ics,
<br /> 6. Tank owner roust submit a facility plot plan to the local agwency as pact of the applic-ation showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(8).CCR],
<br /> 7. Tank owner roust submit documentation shoxringrrsplc ,rcu with state financial r ,fionsibility requirements to the local agency as part of the
<br /> application for petroleum USTs[Suction?7l I (a)(I1),CC,:
<br /> TOP OF FORA."MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the iters that best describes the reason the form is bring completed.
<br /> 2. FACILITYISITE 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 /> TABLE,
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. If the mahzt number is the sante,write:"S-AME'-in proper location,
<br /> 3. Check the appropriate box forTYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,IN'DIVIDL;AL,etc.).
<br /> 4. Check the appropriate box forTYPE OF BUSINESS,
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box9tnsrked"YES,%
<br /> 6. Indicate:the NUMBER ofTA KS at this SITE.
<br /> 7. Record the E.€,A,ID#t or write"NONE"in the space Provided_
<br /> 11. PROPERTY 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"SASE AS SITE"across this section_ Be sure
<br /> to check PROPERTY OWNERSHIP TYPE,box,
<br /> III.TANK OWNER INFORMATION&z.ADDRESS(MUSTBE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION I,If the same,write"SAS AS SITE"across this section, 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 6.7 s,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE.)
<br /> Enter your Board of Equalization(BOE)LIST storage fee account number which is required before your permit application can be processed.
<br /> Registration with the BOB will ensure that you will receives quarterly storage fee return in reporting the per gallon fee due on the number of
<br /> gallons placed in your USTs. The BOB will code persons exempt from paying the storage fee ser returns will not be sent. If you do not have ars
<br /> account number with the BOF:or if you have any questions regarding the fee or exemptions,please call the BOE at 916-322-9669 or write to the
<br /> BOE at the following address Board of Equalization,Fuel Taxes Division,P.O.Box 942579,Sacramento,CA 94279-0001.
<br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2712(a)(I1)
<br /> OF TITLE 23,CHAPTER I6,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 icon-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 NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. [SEE SECTIONS-2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA.CODE OF REGULATIONS.]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county and jurisdici.ion 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 VERIFY THE ACCURACY OF THE
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED 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 YELLOW COPIES, TIME PICNIC COPT' SHOULD BE RETAINER BY THE TANK
<br /> 'BIER. o.
<br /> 6195
<br />
|