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* 0 0 • INSTRUCTIONS FOR COMPLETING- FORM "All GENERAL, INSTRUCTIONS: SECTION 2711 OF TIT 1. 21, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286, 25287, AND 25239 OF CHAPTER 6.7, DIVISION 20, CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT. One FORM "A" shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORNIATION CHANGES. SUMMIT OINLY ONE i i? FOR'vI "A„ for a Facility/Site, regardless of the number of tanks located at the site. This form should becompleted by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANI: INSPECTOR. Please type or print clearly all requested information. Use a hard point writing instrmnent, you are making 3 copies. Tank owner must submit a facility plot plan to the local agencv as part of the application showing the location of the USTs with respect to buildings and landmarks (Section 2711 (a)(8), CCR]. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the application for petroleum USTs (Section 2711 (a)(I 1), CCR). TOP OF FORM: "MARK ONLY ONE ITEM" Mark an (X) in the box next to the items that best describes the reason the form is being completed. 1. FACILITY/SITE INFORMATION & ADDRESS (MUST BE COMPLETED) I. Record name and address (physical location) ofthe underground tank(s). NOTE: Address MUST have a valid physical 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 cif "TANKS at this SITE. 7. Record the E,P.A. ID d or write "NONE" in the space provided. Il. PROPERTY OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) Complete all iters in this section, unless all items are the same as SECTION 1, If the satire, write "SAME AS SITE" across this section. Be sure to check PROPERTY OWNERSHIP TYLE box. 111. TANK OWNER INFORMATION & 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 SITE" across this section. Be sure to check TANK OWNERS TYPE box. IV. BOARD OF EQUALIZATION LIST STORAGE FEE ACCOUNT NUMBER (MUST BE COMPLETED. SEE ARTICLE 5, CHAPTER 6.75, DIVISION 20, CALIFORNIA HEALTH AND SAFETY COBE.) Enter your Board of Equalization (I30E) US"T° storage fee account number which is required before your permit application can be processed. Registration 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 gallons placed in pour LSTs. The HOE will code persons exempt from paying the storage fee so returns will not be sent. If you do not have an account number with the 130E or if you have any questions regarding the fee or exemptions, please call the BOE at 916-322-9669 or write to the BOE at the following address B€.card of Equalization. Fuel Tastes Division, P.O, Box 942879, Sacramento, CA 94279-0001, V. PETROLEUM UST FINANCIAL RESPONSIBILITY (MUST BE COMPLETED FOR PETROLEUM USTs ONLY, SEF: SECTIONS 2711 (a)(I I ) OF TITLE 23, CHAPTER 16, CALIFORNIA CODE OF 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 -petroleum USTs are exempt from this requirement. VI, LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE'BOX for the address that will be used for BOTH LEGAL. AND BILLING NOTIFICATIONS. TALK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. (SEE SECTIONS 2711 (a)(13) OF TITLE 23 CHAPTER 16, CALIFORNIA COTE OF REGULATIONS.) INSTRUCTION FOR THE LOCAL AGENCIES The county andjurisdiction 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 Board to assign the facility number, please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL 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 1S RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER. 6195