|
INSTRUCTIONS "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25236,25257,AND 25259€9F CHAPTER6.7,DIVISION 20,CALTF£ 4NIA HEALTH AND SAFETY CODE REQUIR OWNERS its APPLY FOR IAN tisT OPERATING PERMIT,
<br /> 1, One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES_
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at thesite.
<br /> 3, This form should be completed by either thePERMIT APPLICANT or the LOCAL.AGENCY UNDERGROUND ND 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 ars part of the application showing the location of the USTs with respect to
<br /> buildings and landmarks(Section 2711(a)($),CCR],
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2711(a)(I 1),CCR].
<br /> 'FOP OF FORM:"14 ARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that best describes the reason the forma is being completed,
<br /> L FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> I. 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 /> Include nearest cross street and name of the operator,
<br /> 2. Phone number must have artarea,code. If the night number is the same,a rite"SANTE"in rrtrfser location.
<br /> 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex C`,O.RPORA 1;1(,1N, INEAV I UAL„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 tire NUMBER of TANKS at this SITE.
<br /> 7, Record the E.P.A,ISS 4 or write"NONE"in the space provided,
<br /> 11, PROPERTY OWNER INMORMATIGN&ADDRESS(MUST BE COMPLETE]))
<br /> Complete all items in this section,unless all items are the same as SECTION ,If Olt u same,write"SAVE EA AS SITE"acro ss this section, Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> ITT,TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETE[))
<br /> Complete all items in this sections,unless all'stems acre the same as SECTION I s if the same,write"SAaYIE 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.ED.SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE.)
<br /> Enter your Board of Equalization(BOE)UST storage fee account number which is required before your permit applications can be processed,
<br /> Registration with the:BOE will ensure that you will receive a quarterly storage fes:return in reporting Ilse Per gallon fee due on the number of
<br /> ,gallons placed in your USTs, The BOE will code personas exempt from paying the storage fee so returns will not be sent. If you do not have Zea
<br /> account number with the BOE or if you haveany 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,U,Box 942879,Sacramento,(X194279-tT001,
<br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY(,MUST BE COMPLETED FOR PETROLEUM USTs ONLY.SEE SECTIONS 2711(a)(]1)
<br /> OF TITLE 23,CHAPTER 16,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,UST's owned by
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement,
<br /> VT.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING€ OTIFICA`I`IONS,
<br /> TANK OWNER OR AUTHOR17Et3 REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. (SEE SECTIONS 2711
<br /> (at)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF RE<GUL.ATION;S,,
<br /> INSTRUCTION FOR THE LOCAL.AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(9I6)227-4303. The facility number may
<br /> be assigned by the local agency, however,this number roust be numerical and canner contani`'any°aalp€rabe6cdl characters, if the local agency
<br /> prefers the State Board to assign the facility number,please leave is blank,
<br /> 11" IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSi'EcrS THEFACILITY 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 RETATI"l`I`HE ORIGINAL AND YELLOW COPIES_, THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER,
<br />
|