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INSTRAIONS FOR COMPLETING AM "A" GENERAL INSTRUCTIONS: S[Q TON 2711 OF TTfLE 23,CI IAPI-I;R 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25280 25287,AND 25289 OF CHAPTER 6.7,DIVISION 20,CALIFORNIA HEALI'll AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST'OPERATING PERMIT. 1. 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 PERMIT 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 pan of the application showing the location of the UST's with respect to buildings and landmarks[Section 2711(a)(8),CCRI. 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as pan of the application for petroleum UST's[Section 2711(a)(11),CCR]. 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. FAC11.11 Y/SITE INFORMATION&ADDRESS(MUST BE COMPLETED) 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 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 of TANKS at this SITE. 7. Record the F P.A.ID#or write"NONE"in the space provided. It. 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 OWNI:RSIIIP'I'YPE box. III.TANK OWNER INFORMATION&ADDRESS(MUST B1 COMPLE"TED) Complete all items in this section,uriless all items are the same as SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure to check TANK OWNLRS TYPE:box. IV.BOARD OF EQUAI3LAI10N L'ST S'I-ORAC,1 FEL AC:COUNr NUMBER(MUST BE COMPLETED.SEI:ARTICLE 5,CHAVIT;R 6.7.5, DIVISION 20,CALIFORNIA 11EALTIi AND SAFI I'Y CODE) Enter your Board of Isqualizauion(130E)UST storage fee aUount number which is required before your penttit application can be processed. Registration with the 1301:,will ensure that you wilt receive a quarterly storage fee return in rcponbig the$00)6(61nilk)per gallon fee due on the number of gallons placid in your US T's. I he BOE:will code persons exempt frompaying the storage fee so returns will riot lx sun. If you do not have an account number with the BOI,'or if you have any questions regarding the fee or exemptions,please call the HOC:at 916-322-9069 or write to the BOE at the following address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-Wol. V_ PE ROLEU.\1 US 1 IINANCIAL RE PONSIBILI-I-Y(i41US°I'BE COMPIsiTE:D FOR PE-IROLI:UM US"I's ONLY,SIE SECT IONS 2711 (a)(9) OFTIT'LE 23,CHAPTER 10,CALIFORNIA CODI"OF RF.GULA'DONS.) Id rti,y the mcthoxl(s)used by the owner andlor operator,in meeting the Federal and State final.ial responsibility owfv ,Xl by any Federal or State agency as well its notr•putrolcwn USI are.exempt from this requirement. VI.LEGAL.NOTIFICATION ION AND BILLING ADDIMI'SS Check ONE BOX for the address that will be a>ed for BOTH LEGAL.AND BILLING NOT IFICAT IONS. I'ANK OWNER OR AU"I'IIORIZIi!) AND DA'F£s Tlll.i F0101 AS INI,IC A 1LD1 JS,.F.SI CTIQNS"27'71 (a)(13)OF'ITI LE 23 CIIAPT'ER 16,CALIFORNIA CODE OF IZEGULATIC3.NS.,j , INS'1RUCIION.I,'OR'1'111i LOCALAGL\CIES The county art jurisdicticirt numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The f:iuhty number may be assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. I.f the local agency prefers the State Board to assign the facility number,please leave it blank. IT IS I'llE RESPONSIBILITY OF TILE LOCAL AGENCY THAT IINSPI:CTS THS FACILI'I',Y TO VERIFY TIIE ACCURACY OF'FHE LNIFORMAT'ION. TII1S APPLIC.A"ETON CANNOT BE PROCESSED 1F T11E 130E ACCOUNT NUMBER IS NOT FILLED IN. IILE LCXAL AGENCY IS RI:SPONSIOLE FOR THE COMPLE'110N OF THE "LOCAL AGENCY USE ONLY" INFOR.NIATION BOX AND FOR FORWARDBNG ONE VORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. "FILE LOCAL AGENCY SHOULD RETAIN'l I IE ORIGINALS AND FORWARD'rrIE YELLOW COPIES TO TIIF FOLLOWING ADDRESS.I'rIE PINK COPY SHOULD BE RETAINED BY IIIE TANK OWNER. 193 FORD12DRI