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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS
<br /> SECTION 2711 OF TITLE 23.CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25285,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS T(-,)APPLY FOR AN UST OPERATING PERMIT. . ,
<br /> I. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACIL,I"IY/sI INFaRmAT10N CHANGES, . .
<br /> 2, SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 1 This form should be completed by either the PERMIT APPJAC;ANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br /> 4, Please type or print clearly all requested informaticip,
<br /> 5, Use a hard point writing instrument,you are mak-in-3 colties�_
<br /> 6. Tank owner must submit a facility plot plan to the local algmcy as part of the application showing the'location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(8),COB],
<br /> ,7" Tank ownermust submiu ocumentation showing compliance with state Financial responsibility requirements to the local agency as part of the
<br /> application for petr"ofeurcm USTs[Section 2711(a)(I1),CCRi.
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an( )in the box neat to the item that best describes the reason the form is being completed.
<br /> I, FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1, Record carne 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 6f the operator,
<br /> 2. Phone numbersnust have are area code. If the night.number is the xarne,write"SA. "in proper location. _
<br /> 3. Check the appropriate box for TYPE OF BUIMNESS 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 SITE,
<br /> 7, Record the E.P.A,ID#or write"NONE"in the space provided.
<br /> 11, PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION l;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to cheek:PROPERTY OWNERSHIP TYPE box; '
<br /> III,TANK OWNED INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 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 `
<br /> to check TANK OWNERS TYPE:box,
<br /> IST.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE S,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH ANIS SAFETY CODE.)
<br /> Enter your Board of Equalization(BOE)UST storage fee account nu"rnber which is required before your permit application'can be processed.
<br /> Registration with the BOB 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 BOB will code persons exempt from paying the storage fee so returns will not be sent. If:you-do not have are_
<br /> account number with the BOE or if you have any questions regarding the fee or exemptions,please call the EOE at 916-322-9669 or write to the
<br /> OE afthe following address Board of Equalization'Fuel Taxes'Division,P.O.Box 942879,Sacramento,CA 94279-0001.
<br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST BE COMPLETER FOR PETROLEUM USTs ONLY;SEE SECTIONS 2711(a)(I1) r
<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 resporisibility,requirements.USTs owned by
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE B6X for the address that will be used for BOTH LEGAL AND BILLING NOTIFTIONS:
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND,DATE THE FORM AS INDICATED tSEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county and jurisdi6on numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number may
<br /> be assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the local agency
<br /> prefers the State Board to assign the facility number,please leave it blank"
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL.AGENCY THAT INSPECTS THE FACILITY TO VERIFY Tll _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 RETAIN THE ORIGINAL.AND YELLOW COPIES, TETE FINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER.
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