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<br /> INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> Sl`CTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA 11LALTI-I AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any rACiLIri(/SI'1'1.'LNFORMATION CHANGES.
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facdity/Sitc,regardless of the number of tanks located at the site,
<br /> 3. This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK TNSPF(—O,R.
<br /> 4. Please type or print clearly all requested information.
<br /> 5. Use a hard point writing instrument,you are making 3 copies.
<br /> 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
<br /> buildings,and landmarks[Section 2711 (a)(8),CCR].
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency n part of the
<br /> application for petroleum USTs[Section 2711 (a)(I 1),CCRJ.
<br /> TOP OF FORM:"MARK ONLY ONE ITEIM"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> I. FACILITY/SITE INFORMATION&ADDRESS(MUST BE,COMPLETED)
<br /> L Record name 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 /> RO,BOX NUMBERS ARF.NOT ACCEPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 1 Phone number nunrt have an area code. If the night number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSIINLSS 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 tlicNUMBE-R of TANKS at this SITE,
<br /> 7. Recoid the F.P.A,ID 4 or write"NONE"in the space provided,
<br /> II. PROPERTY OWNER IN-FORMATION&ADDRESS(MUST'BI COMPLETED)
<br /> Complete all items in this section,urdCSS all items are the sarric as SEC'F1ON 1,If the same,write"SAME AS SITE"across this section. .Be sum
<br /> to check PROPF.'RTY OWNERSHIP`TYPE box.
<br /> 111.TANK OWNER 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 TATL box.
<br /> IV.BOARD OFE'QUAI.IZATION USTSTORAGiE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6,75,
<br /> DIVISION 20',&LIFORNIA IIIAL'I'll AND SAFETY CODE.)
<br /> Enter VOLIr Board Of Eg11415Z.nion(1301.,)UST storage fee account number which is required before your pennit application can he processed.
<br /> Registration with the BOE wilt ensure that you will receive a quarterly storage fee return in reporting the SO.(X)6((i1T1111S)per gaJJCXI fCC(111c,On the
<br /> number of gallons placed in your US It's. The BOFwdI code persons exempt from paying the storage fee so roums will not be gcnl. If you do not
<br /> have an account rwinbcr with dw BOE Or if you have any questions regarding[he fee 0rCXCrnp6011S,PICUSe call the,WE at 916 12"90f)9 or writes
<br /> Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacxarnu I
<br /> to thic,BOF at the following address I nto,CA 9,12,79 0001,
<br /> V. PEIROLFUMUS I'l-INANCIAL RESPONS11111-l-ry(N-1US'rBE COMPLETED FOR PrTROI.I.,.UNI USTs ONLY,S13F SECTION'S 2711 (a)(8)
<br /> OFTITLE,23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> IdLrr,ity the rnolhod(s)used by the owner andlor Operator,in meeting the Federal and State financial responsibility requicmc.n1s. IJSTs()�vned by
<br /> any Federal Or Stare agency as well as non-petroleum USTs are exempt from this requirement,
<br /> VI.LEGAL NOTIFICATIONN AND BILLING ADDRESS
<br /> Check ONE BOX for the,aildress that will be used for BOTH LEGAL AND BILLLNG NOTIFICATIONS,
<br /> TANK OWNER OR AUTHORIZEl)RF,11RESENTATIVE MUST SIGN AND DATE THE FORM AS tNINCAT1,11), JSFIFS'I�CTTONS 2711
<br /> 16,CAIJFOR\'IACOI)LOFREGT,'LA'l`IO.-\YS.I
<br /> PtiSTRUCTION FORTIIF',LOCAL AGENCIES
<br /> The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303, The facility number may be
<br /> assigned by the local agency,however,this number must be numerical and cannot contain any alphabetical characters. If the local agency prefers
<br /> 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 THE ACCURACY OF'ITIE
<br /> INFORMATION. '1111S AITLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THELOcAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE IORM"A"AND ASSOCIATED FORM"B'.(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAINTHE ORIGINALS AND FORWARD THE YELLOW COPIES TO TIIE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINE'.1)BYTHE TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE,WATER RESOURCES CONTROL BOARD
<br /> C/O S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3/93 M12ORI
<br />
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