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<br /> INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 1-3,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA 14EALT H AND SAFETY CODE REQ IRE OWNER-5 TO APPLY FOR AN UST 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 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 leaking 3 copies.
<br /> 6. Tank owner must submit a facility plot pian to the local agency as part of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711 (a)(S),GCIO.
<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 2713 (a)(11),C:CR]t
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(K)in the box next to the item that best describes the reason the form is being completed.
<br /> I. FACILITY/SITE,INFORMATION r&ADDRESS(MUST BE COMPLETED)
<br /> L Record name and address(physical location)of the underground rankle),
<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"in proper location.
<br /> 3. Check the appropriate box for TYPE 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 TANKS at this SITF_
<br /> T Record the E.P.A.ID#or write"NONE"in the space provided.
<br /> 1I. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are tate same a.,SECTION I;If the same,write;"SAFE AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box,
<br /> Ill.TANK OWNER INFORMATION&ADDRESS(,MUST"BE COMPLETED)
<br /> Complete all items in this section,ura;ess all items are the same as SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check TANK OWNERS TYPE box.
<br /> IV.BOARD OF EQUALIZATION LST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH,AND SAFETY CODE.)
<br /> .)
<br /> Enter your Board of Equalization(BOE)UST storage feeaccount number which is required before your permit application can be processed.
<br /> Registrations with the BOE will ensure that you will receive a quarterly storage fee return in reporting the per gallon fee due on the number of
<br /> gallons placed in your USTs. The BOE will code persons exempt froze paying the storage fee so returns will not be sent, If yp do not have ars
<br /> account number with the BOE 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 942879,Sacramento,CA 94279-0001.
<br /> V. PETROLEUM UST FINANCIAL,RESPONSIBILITY(MUSTBE COMPLETED FOR PETROLEUM LISTS ONLY,SEE SECTIONS 2711 (a)(I I)
<br /> OF TI'T'LE 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,USTs owned by
<br /> any Federal or State agency as well as non-petroleum USTs are exempt brain this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONh OX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE TETE FORM AS INDICATED. [SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAP'T'ER 16,CALIFORNIA CODE OF REGULATIONS.]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-43()3. The facility number may
<br /> be assigned by the local agency;however,this number inust be numerical said cannot contain any alphabetical characters. If the local agency
<br /> prefers the State Board to assign the facility number,please leai%c it baarak,_
<br /> IT IS THE RESPONSIBILITY OF THE E: t.00A.1 AGEINII- -11AT NS37ECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF TETE POE ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOK. THE LOCAL
<br /> AGENCY SHOULD RETAIN TETE" ORIGINAL AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE"TANK
<br /> OWNER.
<br /> 6195
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