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INSTRUCTIONS I "A."
<br /> GENERAL INSTRUCTIONS-
<br /> SECTION
<br /> NS"T RI.'CTIONS-SEC. ION 2711 OFTITLE,LE,2:3,C:1IAP-l`ER lbs,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25 57;AND 25289 OF CHAPTER
<br /> &7,DIAtT.'ON'20,CALIFORNIA HF°AI ZII AND S.F1,,T Y CODE REQUIRE OWNERS TO APPLY FOR,AN UST OPERATING PERMIT.
<br /> 1. One FORM" "shall to completed for all N LW PEP SIIT CHANGES or any P C I ISI 'E INFORMATION CHANGES,
<br /> 2. SUBMIT ONLY ONE(1)IFC)Rlvl"A"for a Facility/Sit%regardless of the number of tanks located at the site,
<br /> 3, This forgo should be ccnnpletcd by either the I'ER'NllT APP11C:ANT or the LCsCAL AGENCY UNDFIIZC"cktC3U.ND TANK INSPECTOR.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument,you are snaking 3 copies.
<br /> 6. Tank owner roust submitr a facility pleat plan to the local.agency as part of the applidation showing the,locatiiatn of the USTe with respect to
<br /> "buildings and landnnarks,[Section 2711(a)(8),C',C"Rh
<br /> 7. Tank owner tntast submit documentation showing compliance with state financial requirements to the local agency as pat ofthe
<br /> application for petroleum USTs(Section 2711(a)(11),C°Chi.
<br /> ,rop()laE'C)RMI "MAR KONLY ONF: I'['1'M"
<br /> Mark an(X)in the box next to the Aran that best describes the'reason the foran is being completed,
<br /> T. IeACILITY/SITr ErFL)RMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name and address(physical location)of the underground tank(s).
<br /> NOTEAddress MUST have a valid physical location including city,state,and zip code.
<br /> P,O,II(3N NrL MBE'RS ARE.NOTACCE13TABLE.
<br /> Include:nearest cross street anci[name of the operator.
<br /> 2. Phone number mtast have air 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 /> ESS.
<br /> 5, If Fas.tlity/Site is located within an Indian reservation or'r aier Indian trust lands,check the box marked"YES".
<br /> Fs. Indicate the NUMBER of T ANICS at[Itis SITE.
<br /> 7. Record the E.R&ID4 sir write NONE"in the space provided.
<br /> I:I. PROPE'RT'Y OWNER INFORMATION&ADDRESS(MUST BE C{MPI.ETEn)
<br /> Complete all items in this secd an,unless all items are the same as SECTION TION 1;If the same:,w€itc°"S AME AS SI"1`E""across this section, lie sure
<br /> to checFk l'Sa'OP RTY O IaERS1I1P`i`YPE box,
<br /> Ill,TANK OWNER]INFORMATION AA:ADDRIESS(A1US I BE C.C)MPLETE'l))
<br /> Complete all items in this section,Unless all ite nis are the same as SECTION i,If the same,write"SAME AS SITE"across this sccticmn Be,stmt:
<br /> to checkTANK OWNERSTYPE box,
<br /> IV,BOARD OF EQUALIZATION t S't :i"tORAGi,FEE AC..COU 1`IN MF E.R(.vIUST BE C<C)w4 PLE`E13.41iE ARTICLE 5,C:IIAVI 'R 6♦-75
<br /> DIVISION 20,CALIFORNIA III,'..'L I{AND SAFETY Y CODE)
<br /> Inter your Board of hqu,al:4ation(1301"0 1,S I storage fee,account number which is required before your pennon application n can be proecsted.
<br /> Registration with the 1301.",will crnsure that you will receive at quarterly stmage fee return in reporting the S0.W6(6mil )piu" :a',lksn fee due on the
<br /> number c>k'',gafl,ons place:d in your+.S l's., ilne;13013 Will c;o¢.e persons,exempt from paying the storage fee so r„t't rns,will..r,be s..n,a. If you do not
<br /> havt.an acc ount tnun,tbc.r with the 13OE or if you have any questions reearding the fee or exeranl>t ones,please call flip B(1'..at i 16 322 9669 Or xWiRa
<br /> to the 13OU at the:fcalfox.,agaddi s,Boaard of Equalization;Fuel Taxes Division,P,O.Ilos 912879,Sucaa mcnrto,CA 91 r).,0CL
<br /> V. 1`1`11ROL UM UST FINANCl:,'1I.RESPONSIBILITY I IT (MUSTBE E C(')NIPL}:TEI)Ia{)R PE-I,e'{?€E`U. sa t STs t NI,,a,SFX',3 .(A IONS 2711 (a)()
<br /> OF TT'l,I 1.a 4,CIIAP I'E R 16,CAL,Ii ORNIA CODE OF RE.(nILATION'S,)
<br /> Identify gine mcthcx,(S)use}by the,comer and/or operator,in tnnectinng tire.Federal and State fianaanc;i<al reslnonnsibil4y by
<br /> any I cic c l w St:atc ag o ncy as wcil as none-petroleum i.STs aar;exennpt from this€ec,uisernernt.
<br /> VF,LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Cit,A k ONI"BOX foi,dic addess that will be u,cd for B0111 LF(3 AL AND BILLING NOTIFICATIONS,
<br /> TANK C?1t;NI]k OR xAl.,"T1l0lUZl',D RETRESENTATIVE MUSTSIGN ANN)DA E"HE',Iat RNR AS I Nit ICA'11) 1), tslT'S ,{ t',NS,2";'I1
<br /> (a)(13)C)F 1 I I LE 23 C li.Aia;'L R 16,CAIJII�ORNIA CODE,OF REIGULATI)NS.I
<br /> lSTR C71"ION FOR lib.:I>()CaAL;AGENCIES
<br /> The cour`y an yur ,Bette to antrmbe'€are pr,tac;tmminned and can be obtained by calling the Slate,Board(916)227-4303, The(,.cion numb r nr a t;b-
<br /> ass gned by iht Ioctxl agency;howevcr,this number must be.numerical and cannot contain any alphabetical charaactcrs. If the'local agency prcaers
<br /> the State B aid to assign tine facility number,please leave it blank,
<br /> IT IS THE.' OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY "t t) VI R! Y THE ACCU.RACY CIIF'IHE
<br /> INFORMATION, 4 llIS AIIIII.I.A 110377 C:ANNC)1 I3F;PR(YCE;SSED Ila TIIE BOE AC.Ct3UN'I`NU.N!l31:E;IS N'OT I•IL.t,t,'D IN, '111BLOCAL
<br /> AGENCY.IS RESIIONSIIIIJ.' i"C3k THE Ct)V11'I,E ION OF THE LOCAL AGENCY USE ONLY" INFORs"TATION BOX ANIS FOR
<br /> FORWARDING ONE,l t IRM A ;AND ASSOCIATED FORM"I3"(s) IC)THE FOI.IyOWLNCs ADDRESS, 'IFIL;LOCAL AGENCY SHOULD
<br /> RETAIN' THE,ORIGIN A.4.-ANI)a ORWARI)'I HE YELLOW COPIES 1`0 I IIF.FOLLOWING ADDRESS.111L PINK COPY SHOULD BE
<br /> Iz�lal'AlNiltyt§ .l1IEI'rANRCAAN'R.
<br /> '
<br /> STATE OF CALIFORNIA
<br /> ST",1 T&WATER RESOURCES CONTROL BOARD
<br /> C,CIS: E..Fz.t',S.
<br /> DATA PkocESSLNC,CENTER
<br /> P.O,BOX 527 #
<br /> PARAMOUNT,CA 911723
<br /> 3:5
<br /> FOR012ORI
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