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INSTRAIONS FOR GARM COMPLE INttAll
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<br /> _.GE�AE1NSTRUCTJ0NS: '
<br /> sEcT ig"731 OF Tau 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS NS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CAUFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TC[ FOR AN UST OPERATING PERMIT.
<br /> 1, 01*VOMI"A"'ahail,a completed for all NEW PERMIT CHANGES or any FACII,I'I'YfSITIi INFORMAMON-C,HANGES.
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,j�Tegsrflless ofthinumber of tanks located a,the site,,,
<br /> 3. Thittfomishould bcranaplcicd by either the PERMIT APP ICANT'orthe.LOC:AL AGENCY UNDERGRO1tI(1Q.,TANK INSPECTOR: `
<br /> 4. Please type or print clearly all requested information.
<br /> 5.'Use.a,hard point writing instivatcnt,you smj.naking 3 copies.
<br /> 6. Tank owner must subtqut a facility plot pian to the local ilgency-as part 4f the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711(a)(8),CCR).
<br /> 7."Tank owneratusr44hir t documentation showing compliance wait Ott financial responsibility roquirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2711(a)(11),CCR),
<br /> TOP 01^4t3RMa-"MARK•ONLY ONE ITEM„
<br /> Mart an(X)in the boil next to the item that•best describes the reason the fottn is being completed
<br /> L :FACILITY/SITE INFORMA`1014&ADDRESS(MUST DE COMPI3r D)
<br /> 1. Record name and address(physical location)of the underground ttta{►{tt)..
<br /> -:MOTE:Addtnsslt4UST have a valid°physical location including city,atate,and zip code..,
<br /> P.O BOX NUMBERS ARE NOT ACCT PI`ABLE,
<br /> Include pcamst cross street arid name of the operator.
<br /> Z. Phone number must have an area code. If thenight-number is he sar�t!,rwrite"SAME'•in proper location.
<br /> 3.Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.CORPORA`110N,INDIVIDUAL, aq.).,
<br /> 4. Check the appropriate box for-TYPE OF BUSINESS.
<br /> 5.if Ftiellityl§ite3fi 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,Ar ID#oNr'wr to"NONE"in the space:06( ded:
<br /> s-II. PROPERTY OWNER INFORMATION&ADDRESS(MUST-BE COMPLETED] w..
<br /> Complete all items in this section,unless all items are the same as SECTION I;lf-t4rrei wn#a"SAME Ara SITE"across this section, Be sure
<br /> to check-.PROIILRTY OWNL.'RSI IIP TYPE box.
<br /> III.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> C4- loft allitctrts in this section,unless all items are the same as SECTION I if the-same,write`SAME AS'SITE"across this section. Be sore
<br /> to�hecl:TANK 01 &NWS TYPE box, l
<br /> IV.I3OARl?OF LQ[JALl2A1T0 4 L'ST STORAGE FL'E ACCOUNT:titI,CRBER(MUST DE COMPLETED.SEE ARTICLE S.CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA IIEALI.11 AND SAFETY CODE:y
<br /> Enter your Board of'E411ali2aLion(BOI•s)UST storage fee accoiintnumber which is retluarcd b fare ycwr Ix nn;t applic;riyn can be processed.
<br /> Registration with the BUL uill•ensure that yeti unit receive a quarterly storage fed t-u*in'pepoitingthin$€kiDO�i fNnillsj•}�er g;tlionfee duo on the
<br /> number ofgallons+faced to aur LISTS..The B0,E n ii(code >crsops,gxctnpt from payin -the storage fee W.rcwms.ti+;•.ill not he sem. 1('you do not. '
<br /> have an account numberw'ith the BOI:ur if you have any questions rtgarducg,tlie`idc tarexctttptiiass�rlusa raft the};Ui;;aF916-322-1669 or write
<br /> tethe BOE at the following add?s Board of Equalil•.ation,l�oel T''axes Division,.P.O.Box 942879r.-Sacramento,CA 94279-0001,. ,
<br /> J V. PETROLEUM US7`FEQANCIAL.R ,-;P.)NS3F3II,ITY(Mus,,FSE CO 11('LEZ f D FOR PE-IAOI.I UIti4 US is Ot1,11SI I' 'C'.1 IONS 2711 (a)(R)
<br /> OFTi L'23,CHAPTER-1.6,CALIFOIR\IA CODEOI R1:Gl LA7'}Oitips) - t.•
<br /> Identni'y the method(s)used by the owner and/or oper ,ucr,in,rrtecting the F ederal�and State financial resptitts i(ity reclu.r..ut nts. LS I's owl.cd by
<br /> any Federal'Or State agency us•well its non•petrolcuin t STs°are exempt from this rcquirement:
<br /> VI.LEGAL NOTIFICATION AND B11.I1NG ADDRLSS-
<br /> Check ONE 13OX for the address that t ill be u :ed for 130'111 LEGAL AND BILLING NOTTI-IC"A'IJ0NS.:'
<br /> TANK OWNER OR AU771ORIZI.-.D REPRESENTATIVE mus'r SKIN AND DATE 1111:FUR`�1 AS INII)kAI1:]). I S1:Fi SECTIONS 2711
<br /> (a)(I3)OF TI-II.0 1,3.CIIAP•1'E3R.16,CA1.II:OKNIA CODI OF REGULATIONS
<br /> INS'1RWnON FOR Tlll'"LOCALAG4;NCIES _-
<br /> The county an jurisdiction nufnbers arc predetermined and can be obtained by callirti the Statc 136*,-(y16)227-43173; "the taiility number may he
<br /> assigned by the-Iocal agency;however,this nunttner-must be rntmericat and cannot co'WAin:at y alphabetic al citaractcrs:if the local agency prefirs
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT..-IS THE RESPONSIBILITY OF TINE.LOCM.AGENCY TFEAT INSYISCTS mAQLITY TO:V1 'RIFY 114 ACCURACY OF TTIE
<br /> E\TORSSATTO\
<br /> THIS APPLICATION CANNOT BE PROCESSED IF THE BOE.ACCOLNT NUMBER IS NOT FILLED IN. T1IE LOCAL
<br /> AGLi`OX IS RX$PICi\ I lrL' FOR T'IlL COhiPLET'IO f OF`III>r LOCAL AGi C ' Sl"O1NLV' INFORMATION I$OX AND FOR
<br /> FORWAI€13SNG'f 1e'I`I O 1"A"AND ASSOCIA11:t?FORM'"D"(s)TO THE FOLLOW IiL AdDittS3: THE LOCAL AGENCY SHO'bl D
<br /> RETAIN THE,f?dGINAF:'.. AND FORWARD THE YELLOW COPS$;- —ftlEPOLLt'}'ClrM-e 'A-DDRESS.,THE PINK COPY SNOUW HE
<br /> RI.-TAI.NLD BY TIIETANK OWNER.
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<br /> 7 3193 FOR0140R)
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