|
INSTRUCTIONS FOR. COMPLETING FORM "At'
<br /> GENERAL INSTRUCTIONS:
<br /> &F :I ION 271101"1 ITLE23,CHAPTER 16,CALIFORNIA CODE OF REGULATION'S AND SECTIONS 25246,25287,AND 25289 OF CHAPTER
<br /> , C
<br /> 63,DIVISION 20,CALIFORNIA 11 EA LTH AN 1)SAFETY CODE REQUIRE OWjNLRST0 APPLY FOR AN UST OPERATING P13RM.FL
<br /> 1. One FORUM"A"shall be completed for all N LW PERMIT CHANGES or any FACILITY/SrrF INFORMATION CHANGES.
<br /> 2. su,8mrr ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site.
<br /> 3. This form should be conipleted by either the PERMIT APPLICANT or the LOCAL AGENCY UNDE:RGROUND TANK INSPECTOR.
<br /> 4, Please type or print clearly all requested information.
<br /> S. 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 pan of the applicAion sh'owi.Ag the location'of the USTs with respect to-
<br /> buildings and landmarks[Section 2711 (a)(8),CCRI .
<br /> 7. Tank owner must submit documentation showing co rppliaice with. state financial re.4poA,tiwil.Y ie4ui'yv.m.en ts tothe local I agcAcy as par I t of the
<br /> application for petroleum USTs[Section 271 1,(a)(I 1),CCRJ.
<br /> TOP OF FORM:`MARK 6NLY ONEITEM"
<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 /> 1. Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city,state,and 2,ipcodel
<br /> 11,0.BOX NUMBERS ARE N T ACCEPTABLE.
<br /> lilclude nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. If the night number is the same,write"SAME"in proper location.
<br /> 3. Check the appropriate box for TYVE OF BU.SENESS QWINTERSHIP(ex.CORP-ORATION,INDIVIDUAL,etc.).
<br /> 4. Gheck-the.appropriate box for I 1Yj)E OI:BUSINESS
<br /> 5, If Facility!sitc is lc Bated within an Indi4wreservation or other 1;1dian trust lands,check-the box marked"YES".
<br /> 6:-Indicate thc3NUM BER of'FAN Sat this SIT E,
<br /> 7. Recoitl the E,P.A.ID#or write"NONFin the spa.lirc)vistc 3.
<br /> 11, PROPERTY OWNER INFO1ti'MA'1710N&ADDRESS(MUST BE C)VPIXTFD)
<br /> Complete all items in INS scctiool unless all items are the same as SE(7110N 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWiNERSI 1111 TYPE box.
<br /> III.TANK OWNER I.NFORNIATION&ADDRF,,;S(LIUST BE COMPLETED)
<br /> Complete all iternS in this SCC60n,Unless all items are the same as SECTION I;If the same,write"SAME AS SITE'I,ta.(AoSthis sel(Acyn,'Be Fufe
<br /> to checkTANK O'NNLRSTYN, box,
<br /> IV,liOA10)OF11QUALIZATION US S�TORAGE ITE ACCOUNNTNUMBIiR(MUST'13E COMPLE-11,J),SEJ-,ARTICLE'.5,CilAvrl,R 6.75,
<br /> DIVISION 20,CALIFOWNIA IiliALTH AND SAIT,.TY CODE.)
<br /> E.'ntCT your Board of Equalizalion(110E)USTstorage fee account nornberAhich is required before your NnPit aj,pli, d
<br /> Registration Will)111c BOF will ensure thatyou 1xill receive a quarterly storage fee return in ropoyline thn S )M'O
<br /> 1,1te 130E will I code persons exempt from paying 11C a C so% 1
<br /> li:ive.an account nurnbcr v,:jtI)the.BOl.",or if sou have any questions regarding the fee or
<br /> to the BOF at the folloaillg addjcs,,,llo_(f of Equalization,Fuel Taxes Division,11.0.Box 942KX"'),
<br /> V, mil`lRol.1"L1m usf,1-i'NANCIAL Rl-'SPONS113ILITY(MUS'l jll-CO-1,4111 ETE"D I�OR 111:3 ROLII.'IJMI USTs ONLY,SEli SI�C:1 i�
<br /> OFTI-II l23,CIIAII FE'R 16,CALE'OR. 1A CODE OF REGULKIIONS.)
<br /> Identify the xnc.11itxffs)useJ by tile,owner andjor Operator,in meeting the Fc&,ral and State financial resPonsibility
<br /> any lFedef A or State agency as well as non-petroleum petrolcurn USTs are exempt front this i equiumient.
<br /> VI,LEGAL NO-11FICATION AND Bll-LING ADDRESSA
<br /> Check-ONE BOX lot he address that will be used for BOIJI LE'GYAL AND BILLING NOI IFICA110N,"",
<br /> TA','KOWNI'ltO1 At.'*I'IlOIZ,IZI,'I)REIIRI,'Sf!.N'I'Al'IVE.NIL S'I'STUN AN'1)1)A'1'1.,''I'llf..-I:OIZMASINI)IC,N'i'1:1),
<br /> (a)(13)OF'I ITI-F,23 CIIAIII'ER 16,CALIFORNIA CODE,OF REGULATION'S.1
<br /> m?S4b:7nC'1N IO'R Tiil:I..(-),CAI-AGENVIFS
<br /> are pr-determined and can beobtained by calling the Stale,Board(916)227 430— flu nonbLrmay bc
<br /> assigned by the,local agcncy;however,this number must be nurne6cal and cannot contain any alphabetical characters. ffthe local agency prefers
<br /> the StXe Bmittl to assign the facility number,please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY 10 VI.RIFYTllI` ACCI,,'RACY OF"LTTE
<br /> INFORMATION, TI IIS A Ill ILICATION CANNOT BE PROCESSED IF TI IE BOE ACCOUNT NUMI BER IS NOT F11.1-1,J)IN, 11[flincAl-
<br /> AGENCY IS RESPONSMI-E FOR THE COMPLF'RON OF THE "LOCAL AGENCY USE ONLY" VNFOJ�NMATION BOX AND FOR
<br /> FORWARDLNG ONI;FORM"A"AND ASSOCIATED FORM"B`(5)TO THE FOLLOWINIG ADDRESS, THE'LOCAL AGENCY SHOULD
<br /> RI T,UN 11 If.; OR.lGfNALS AND FORWARD"THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RE"TAINE'D.BY'l 11I.-TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATLR RESOURCES CONTROL BOARD
<br /> C/O S.W.E.ET,S. I
<br /> DATA PROCESSNG CENTER
<br /> P.O_BOX 527
<br /> PARAMOUNT,CA 90723
<br /> FOR012OR1
<br />
|