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INSTATIONS'TIONS F°O COMPLETING901RM "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 O F TITLE 23,CHAPTER 16,CALTFORSIIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER _
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN LIST OPERATING PERMIT.
<br /> 1. One[FORUM"A"shad be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CfI<LNGFS._
<br /> 2. S(JF3:MI.T ONLY ONE(l)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 instrument,you are making 3 copies.
<br /> 6. Tank owner must submit a facility plot plan to the local agency as pare of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(L),CCR]. N:-
<br /> 7. Tants owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for pcirolc urn USTs[Sec:ti rr 2711 (a)(I1),CCR].
<br /> TOP OF FFORX1:"NI ARK ONLY ONE ITEM"
<br /> Mark an(X)in the 1>ax next to the iteral that best describes the reason the four is being completed.
<br /> I. FACILITY/SITE INFOR'sIATION A A1)DRI,SS(MUST Bh C OMPLETED)
<br /> I. Record name and address(physical laxation)of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city,sate,and zip code.
<br /> P.O.BOX NUMBERS ARE ti0'T ACCET'TABLE.
<br /> Include nearest cross streett ar)d name of the operator,
<br /> 2. Phone number roust have air area code. If the night number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate box forTYPE OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5. If Facility/Site is located within an.Indian reservation or other Indian,trust lands,check the box marked"YES".
<br /> 6. Indicate the NUMBER of`I'ANISS at this SITE.
<br /> 7. Record the ET.A,117#or write"NONE"in the space provided.
<br /> M PROP1 R 1 Y OWNER R INF C}a1M I TON &,.�DDRLSS(MUIST BE COMPLETED)
<br /> Complete all items in thk section,unless all i;casts are the same.as SECTION 1;If the same,write"SAME AS SITE"across this sectiom Be sure
<br /> to cheek 11ROPER°T Y OWN 1,,,RSI11i'`i`YPIa lox,
<br /> III.TANK OWNER F
<br /> LN t3RMYNTION&AD'S IRES'S C,UST BE COMP-LE.111y)
<br /> C"e>mplec all'Items in thk section,urdess all items are the same as SEC"IION 1;If the same,,write"SAME AS SITE"across this section Be sure
<br /> to c hcc;k TANK O\'i'Ni"RS TYl'I box.
<br /> IV,BOARD O F I-,Q1;AI:IZA I l0N USTSTORAGE ORAC,L F 1.FE ACCOUNT.N'UMBFIR(MUST BE COMPLETED.SEF:ARTICLE 5,CHAPTER 6,°75,
<br /> Elmer year Board of Equalization(1101)UST storage 1,ce account number which is required I. fora:your permit application can be processed.
<br /> Rc;rstsatiorr v';th th:e ll()t:will nscarc that yott will receive a quarterly storage fee remrn in reporting the SO)006(6mill,}per gallon fee due on the
<br /> nut tn.„r of gallons p'sa.,d gra yes;r VS Is. 11hW BOE will code parsons exempt from paying the storage fee so returns will not he sent. Ifyou donor
<br /> bavv taceo a}t t ufnb t s a.I t'a 301 or s' you hatic luny quc stions regarding the fee or exemptions,please call the l3C)1 st s}16-322=t}fsf 9"or write
<br /> to 111C BOE at riau 4o1 ou uta dc;:css Boar i of t_,laalaration,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 1)"27€9-buo`i.
<br /> V.
<br /> OlF 171 LL°.2l,CHAPTER 16,CA1,1IFORNIA CODE 01,REC,UI,ATiONS.)
<br /> I<cr atr'y the ttt tl,x ts)used by tt e,oweer andlor operates,inanectutg the Federal and State financial reslx>nsabilay rcquiitencnm L SI'a-owns d by
<br /> any I cderal of 4f>ta agency as well as fron-p etruleum USTs are exempt from this requucanent�
<br /> VT.LEGAL 017.1F1C:A"ZION AND BILLING ADDRESS
<br /> Check ONEBOX for the address that will be used for I3C1TH LEGAL AND BILLING NOTIFIC:ATIO,,s.
<br /> "1'A.N'K(.)4,"y,'It OlI At'1'1101Z'.Zkil?REI'RESE:N'I'A`I'IVE ML;'S1'SIC,N ANl)DA'l'[ `1'111::i°ORM AS IND1C'A-1'1:17. (Si.>I SEC TIONNS 2711
<br /> (a)(13)OF TI LE"23 C1!All H1,'.R 16,CA;LFORNIA CODE OF REGUL A 1'1ONS.)
<br /> INSTRUCTION FOR"1 HE LOCAL AGENCIES
<br /> The;county an jurisdiction nt:arabcrs are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number may be
<br /> assigned by the local agency;however,this number must be nutnerical and cannot contain any alphabetical.characters. If the local agency prefers
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS T1IE RESPONSIBILITY OFTHE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> ]INFORMATION, THIS APi'L'I,CATION CANNOT BE PROCESSED IF THE 130E ACCOUIN T NUMBER IS NOT FILLED IN, THE LOCAL
<br /> AGENCY IS RI SI'ONSIBLh FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONEFORM"A"AND ASSOCIATED FORM”T3"(s) TO THE FOLLOWLNi l ADDRESS. TIIE LOCAL AGENCY SHOULD
<br /> R11TAINI THL ORIGINAIS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINEID 13Y T11E TANK OWNER, ,
<br /> STATE 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
<br /> FORD12DRI
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