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;r i INSTRUCTIONS FOR COMPLETING FORM "A" GENERAL INSTRUCTIONS: SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286.25287,AND 25289 OF CHAPTER 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMTT. 1. One FORN4"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES. 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the numberof tanks located at the site. 3. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument.,you are making 3 copies. r> 6. Tank owner must submit a facility plot plan to the local agency as part of the application showing the location of the USTs with respect to buildings and landmarks[Section 2711(a)(8),CCK]. 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part oi`the application for petroleum LSTs[Section 2711(a)(11),CCR]. TOP OF FORM:"MARK ONLY ONE ITEM" Mark an(X)in the box next to the item that best describes the reason the form is being completed. I. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED) 1. Record name and address(physical location)of the underground tank(s). NOTE: Address MUST have a valid physicai location including city,state,and zip code. P.O.BOX NUMBERS ARE NOT ACCEPTABLE. Include nearest cross street and name of the operator. 2. Phone number must have an area code. If the night number is the same,write"SAME"in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,,etc.). 4. Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box marked"YES". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A.ID#or write"NONE"in the space provided. II. PROPERTY OWNER INFORMAT1ON&ADDRESS(MUST BE COMPLETED) Complete all items in this section,unless all items are the same as SECTION 1;If the same,write"SAME AS S11 E"across this section. Be sure to check PROPERTY OWNERSIIIP TYPE box. III.TANK OWNER INFORMATION&ADDRESS(MUSTBE COMPLETED) Complete all items in this section,unless all items are the same as SECTION l;If the same,write"SAME AS A-1-across this section. Be sure to check TANK OWNERS TYPE box. . IV.BOARD OF EQL'Ai.1ZA'ITON USI'STORAGE FEE ACCOUNT NUMBER(MUST,BE COMPLETED.SEE ARTICLE 5,CIIAP'ITR 6.75, DIVISION 20,CALIFORNIA I1EAL-I'll AND SAFE'L'Y CODE.) Enter your Board of Equalization(130E)UST storage fee account number which is required before your permit application can be processed. Registration with the BOL^will ensure that you will receive a quarterly storage fee return in reporting the$00)6(6mills)perggallon fee due on the number of gallons placed in your USTs. ITic BOE wilt code persons exempt from paying the storage fee so returns will not.be sent. If yew do not have an account number wide the 130Eor if you have any questions regarding the fee or exemptions,please call the I30E.at 916-322-9669 or write to the BOF.at the following address Board of Equalization,Fuel Taxes Division,R.O.Box 942.879,Sacrament'&,CA 94279-0001. V.-PETROI..Iium US 1'FINANCIAL RESP0NS1.I31I.I -Y(MUST BE COMPLETED FOR PETROLEUM USTs ONLY„SEE SECTIONS 2711 (a)(8) (7.F TTT'I.I:23,CHAPTER 16,CAI_IFC)RNIA CODEOF REGULATIONS.) Identify the method(s)used by the owner and/or operator,in meeting the Federal and State financial responsibility requirements..USTs owned by any Federal or State agency as well as non-petroleurn UST's are exempt from this requirement. VI.LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE I30X for the address that will be used for BOTH LEGAL AND BILLING..NOTIFICATIONS. ` TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. (SEE SLC';'t'IONS`2711 (a)(13)OF T ITLE 23 CI IAln'I:R 16,CALIFORNIA CODE OF REGULA'IIONS.] 1NS'IRUCI1ON FOR THE LOCAL AGENCIES The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number may be assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the local agency prefers the State I3oard to assign the facility number,please leave it blank. IT IS TITE RESPONSIBILITY OF THE I.;OCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT"FILLED IN. THE LOCAL AGENCY IS I21iSPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD RETAIN TITE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O S.W.E.E.P.S. DATA PROCESSING CENTER P.O.BOX 527 PARAMOUNT,CA 90723 3'93 FOR0120R1 •