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INSTR#TIONS FOR COMPLETINGFORM "Alf GENERAL INSTRUCTIONS: SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER 6.4,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT. L One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES. 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site. 3. This form should be completed by either the PER.'vlIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 4. Please type or print clearly all requested information, 5. Use a hard point writing instrument,you are making 3 copies. 6. Tank owner must submit a facility plot plan to the local agency as part of the application showing the location of the USTs with respect to buildings and landmarks(Section 2711(a)(8),CCR]. 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the application for petroleum UST's[Section 2711(a)(11),CCRJ TOP OF FORM:"MARK ONLY ONE ITEM" Mark an(X)in the box next to the item that best describes the reason the form is being completed. I. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETE-D) 1. Record name and address(physical location)of the underground tank(s). NOTE: Address MUST have a valid physical location including city,state,and zip code. P.O.BOX NUMBERS ARE NOT ACCEP'T'ABLE. 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 of TANKS at this SITE. 7. Record the E.P.A.ID 0 or write"NONE"in the space provided, 11. PROPERTY 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 PROPERTY OWNERSHIP TYPE box. III.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 USTSTORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED,SEE ARTICLE 5,CHAP`I-ER 6.75, DIVISION 20,CAIJFORNIA HEALTH AND SAFETY CODE.) Enter your Board of F',qualiza-Lion(BOE)UST'storage fee account number which is requited before Your perinitappfication can be processed. Registration with the BOL will-ensure that you will receive a quarterly storage fee return in reporting the$0.006(61nills)per gallon fee due on the number of gallons placed in your LjSj's. The BOE will code persons exempt from paying the storage fee so returns will riot be sent. If you do not have an account number with the BOE or if you have any questions regarding the fee or exemptions,[)Iuase call the BOF at 916-322-9669 or write to the B011at the following address Board of Equalization,Fuel Taxes Division,11.0.Box 942879,Sacramento,CA 94'279-0001 V. PETROLE"UM Uri TFINANCIAL RE'SPONSIBILITY(MUST BE COMPLETED FOR P111ROLEU-NI LSTs ONLY,SEE SE'C'TIONS 2711 (a)(8) 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 rcquircnic;nis. (DST's owned by any Federal or State agency as well as non petroleum US*rs are exempt from this rcquirerricrit, VI.LEGAL NO'11FICATION AND 13111,11NG ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS. TANK OWNER OR AU'1'110RIZI.-DREPRESE.,N7ATIVE MUST'SIGN AND DATLT1111'FOWNI AS UNDICATED. JSFI1-'1SECTIONS T7ll (a)(13)OF TITLE 23 CHAP l'ER 16,CA11FORNIA CODE OF REGULATIONS] INSTRUCTION FOR TT 111'LOCAL AGENCIES The county an jurisdiction numbers arc 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 nurnber must be numerical and cannot contain any alphabetical characters. If the local agency prefers the State Board to assign die facility number,please leave it blank. IT IS THI-3- RESPONSIBILITY OF TILE 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. TlIE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD RETAIN TILE OIRIGINALS AND FORWARDHL YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE R E.11A I\E 1)BY TI I E,TAN K ONk"N E R. FOR012DR1