|
INSTRtI N
<br /> O S FOR.COMPLETINGARM A
<br /> I✓NERAL SINSTRUCTIONS: �' s
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AINUSECTIONS 23286,25287,'AND 25289 OF CHAPTER
<br /> 6.7,DWISION 20,CALIFORNIA HEALTH AND SAFTY CODE REQS,IRE 010 Fok-I N UST OPERATING PERMIT.
<br /> a
<br /> I.?One FORM`"A"84H be completed for all NEW PERMIT EHANCrES or anY*ACU fJltY,/,SjB'lti INFORMATION CHANGES. �
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the nu •, o tlntksnjtpct#;
<br /> e
<br /> 3. Thiklorm should be.coWleted by either the PERMIT APPI:,ICANT or they . Ct$O D TA.Nk TNSPECTMR
<br /> A. Please type or prvitcicady all requested information.
<br /> g w r
<br /> S. Use a hail point wrting,igstrument,,y'ouare making 3 copies. , • ,r •• ,
<br />• 6. Tank owner must submit a facility plot plan to the local.ag&wy as pan of the., plicar ion showing the Mort the USTs with respmto
<br /> buildings and landmarks[Section 2711(a)(8),CCRI.
<br /> 7. Tank owner must submitjlocumentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum USTs[Section 2711(a)(1 l);CCRI.
<br /> TOP-OFF0RM:7MARKbih`-'VONEITEM"
<br /> Mark an(X)in the box next to the item that best describes the reason'-the fomtu being OoMpleted.
<br /> I: FACIUTY/SITE INrFQRMVnON&ADDRESS(MUST BE COMPLLIED). r d
<br /> 1. Record name and address(physical location)of the underground tank{s)
<br /> NOTE: Address MUSTtion including citystateand zi
<br /> _hsve a valid physical loca , , p cele.
<br /> R0 BOX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest crass street acrd name of die operator,
<br /> 2. Phone number must have an area code, If the night number is the saniC wrete''SA I'll"in proper location.
<br /> 3 " . ( )
<br /> Check the;a}lpropr}ate box fox TYPE OF:BUSINESS OWNERSHIP ex.CORPORA410N,LNI}lvlE)L�L,etc. . _
<br /> 4.Check the a-p—Pw for"TYPE OF`BUSINESS. t
<br /> 5, If Facility;/Site is lb6ated within an Indian.reservation or other Indian'tsust lands,.heck the box marked"YES":
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the.1PA.IDN or write"NODE"in the space provtti`ed.
<br /> IL PROPERTY OWNW IN FORMATION&:ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this.scetion,unless all items are the same as SECTION 1;jf to same teutt '"E AS SJTE";!czoss this section.Be st�na.
<br /> '.toch; eck PROI'l.�'.RT'Y.flWNERSHIP TYPE box. a - x• :. - ;r.
<br /> III.TANK OWNER INFORMATION 8r ADDRESS(MUST I3 BE COMPLETED)
<br /> 1-'
<br /> Complete all tit tits in this section,unless all items are ilte same•as SECTION 1;If the came write-A9XNk8 AS SITE"across this secctiun.'Ba sure q
<br /> to check-TANECOWi\I;IZS TYPE box.
<br /> IV.BOARD OF EQUALIZATION UST STORAG E,FIE ACCOUNT NLM2 � .
<br /> t T BER(,MUST BE CO`MPL$`C'IiD SLE�AIZ,TIG1.E S,Cl IAP1'ER 6.75,
<br /> DIVISION 20,CAI IFOIZNIA IIEAI I II ANI)SAFETY CODE.)
<br /> Enter youF%ard of I3q641raaiiurt(130I:)LST storage fee account number which is required befete your •ntmit a ilicnncti can b processed.
<br /> Registraticai with the 13OL•will ensure that you will receive a quarterly storage fact return;in rt t AA rlie�iXJC( 11A!s)per gat"fee dire txi the
<br /> number of gallans}ilaccd'in your LSTs.the 130E will code persons exempt from paying.,the sttir"ag;s fee � 'rc tlrrriz sill not be surx. .If you donut;:
<br /> have an account number withithe 1301;w�if you have any questions regarding iht(t or ctttiii gP film 4.calfdic'IiOG:rt 916-322-9669 or write
<br /> to the 40E at the follo+vuig adldress-Buard of Equalization,Fuel Taxes Division;P.O,Qox 94287+3,Sacramento;CA 94279-0001:
<br /> •V. PE`I'ROLUUNI US 1 I1%l NCIA1-E E$PONSIBJI,I"(Y(MU-ST BE C>omPI ETL'D FO RI>Li'IRC3LECJ4'I1? Cs O\I Y,SI I SECT IONS 2711 (a)(9)
<br /> OF TITLE 23,CHAPTIrRlb CALIFORNIA CODI 01 I2J GUI AT10NS.).
<br /> ldanttty thtr,rrt�Ihcx'(s)ust cl by'thuowner andlor operator,in meeting the Federal and Stit3'fuA<ulciallt;spcxis"ttlili1j,rcq i.r,.aai,.nts.L'S'I s owl led by
<br /> any'Icderal or State aptic�y trk well as non petroleum USIs are cxcrnpt from this rcqutretmq=, -
<br /> VI.LEGAI-NO 11FICA 1lt),ti A\D BlC t.iNG,1t t}rtl.SS
<br /> Check ONE*BON for the address that will be u•cd for BOTI1 LE.GALANI)F31I..LIN(, ti01 J1=l c'lllt�?NS [ -F
<br /> TANK OWNER OR AUTHORIZED REI'RI SE\`I:A7'IVE MUST'SIGN AND DATH 1'111'1'Ot0, As LNI71ff A 1`:D. I S1.1:SECTIONS T711
<br /> (a)(13)!OF 1111 C 23 GIIAJ!T IER 10,CAMFORIiIA C6 D1,OC REGULATIO
<br /> INSMCI7ON FOlt 1111 LOC.A)_GL,NC1E;S a
<br /> The county an jurisdiction ittktttlxrs are pndcirrmincd and can Eie o►xt*ned by calling the State E3osf�fr916s 2 A3f 3. Ilt<i C,cilit}number may he
<br /> assigned by the local agency-,bonever;thirs number-must be numerteal-.and-cannot contains Any 31T,ls#tmbi;aP2}igractet$: if the local agency prefers
<br /> the State Board to.assaltcgfllity number,please leave it blank• }} „
<br /> ITIS THE RESPONSIBILITY OF.TIIE LOCAL AGENCY THAI'�rSl'ICI�Ti3$;.I-ACIL.IT T �Y�IZEI�TIIF AIC-CURACY�Q1 HE
<br /> INFOR.!'A'I1.O\ Tl 119 APPLICATION CANNOT BE PROCESSEIO 1F THE BOE ACCOUNT NUM ER IS NOT FILLED Lit. THE LOCAL
<br /> A(r. Nt Y,IS 121,51'0\"S1E3I L FOR TfIE Cfl1Nil'LEJ'lON,OF TIE 10C�AI.,AG��'CY , 0,1I,Y"I'N't'0,1t1Y1i1TIOlV,807 ANIS FOR
<br /> FONWARDIN ONE l'OfLSI 'A AND ASSOCIATED E'Olz*JI` B"(sj TO THE 1 Oi,I C1Vl'ITSCi 11I3DIZr . THE LOCAL AfiENCY SHOULD
<br /> " RW,TACN. JIL f3TttGINALS•AND FORWARD THE YELLOtrtr:C'OPIFS'IY71111�, ADDRESS.THE-PINK COPY SHOUL,SIs.
<br /> KETAL\Fill B3 Y IIIE TANK OWNER.
<br /> 3x9301
<br /> FORQt2flRt
<br /> yy,
<br />
|