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INSTRUCTIONS FOR COMPLETING FORM "Art
<br /> GEN:ERA:L INSTRUCTIONS:
<br /> SEC IO 2711 OF"11`l'IA!"23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA IWALTH AND SAFETY CODE REQUIRE OWNERS TO APPI;Y FOR AN UST OPERATING PERMIT.
<br /> 1, One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES.
<br /> 2. SUBMIT ONI..Y ONE(1)FORM"A"for a Facility/Site,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 INSPECTOR.
<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 submita 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),CCRJ.
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleum UST's[Section 2711(a)(11),CCRJ.
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that best describes the reason the font is being completed.
<br /> I. FACILITY/SITE INFORMA'11ON&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name and address(Ithysical location)of the underground tank(s).
<br /> NOTE: Address MUST have a valid physical location including city,state,and zip code.
<br /> P.O.I3OX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include 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 TYPE OF BUSLNESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5. If Facilityj5ite is 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 ID li or write"NONE"in the space provided.
<br /> If. PROPERTY OWNER INFORMATION&ADC?RPSS(MUST BE COMPI.ETF.D)
<br /> Complete all items in this section,unless all items are the same as SECIION 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSH1I'TYPG box.
<br /> IFI.TANK OWNER INFORMATION&ADDRI3SS(-�v1US"r BE COMPI.ETED)
<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.'1'ANK OWNERS TYPII box.
<br /> IV.BOARD OF EQUAI,.IIATION LIST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CIIAl"FE'R fi 75,
<br /> DIVISION 20,C:AI,.IFORNLA HEAL.T11 AND SAFETY CODE.)
<br /> Enter your Board of L:qualizat.ion(BOE)UST'storage fee account number which is required before your pennit application can tie processed.
<br /> Registration with the BOE will enure LhW you will receive a quarterly storage fee return in reporting the SO.W6(6miIN)per gallon fee due on the
<br /> number of gallons plac A in your UST's. "Ihc 130E will.codc person&exempt from paying the storage fee so returns will not be-sou.. If you do not
<br /> have an account number with the;BOE or if you have any questions regarding the fee or exemptions,pleasa.call the BOIi at 916-332-9669 orwrite
<br /> to the I3OE at the fbllox ag addr,ss Bo::rd of Equalization,Fuel Taxes Division,P.O.Box 942879,Sac-ramente,CA 9-1179-0001.
<br /> V. PF.'iROLI L M USI'FINANCIAL RI SPONSIBILITY(MUST BE COY4PLF.TE1)FOR IIE,FROI.,tiUM UISTs ONLY,SPI s1 CI IONS 2711 (a)(S)
<br /> OF TTTLF.23,CHAP IT:R 16,CALIFORNIA CODE OF REGULATIONS.) .—
<br /> Idew ify the mctlxxl(s)used by the owner and/or operator,in meeting the Federal and StatefinancialresgotiSilaility rcquu .ULnBs 1 STs"es nod by
<br /> any Fcdca A or State agency as well as non-petroleum USI`s are exempt from this tequitcrnent.
<br /> VL I,EGAI..NOTIFICATION AND BILLIi4G ADDRESS
<br /> Check ONEBOX for the address that will be used for BOTH LEGAL AND BILIANG NOTIFICATIONS.
<br /> TANK OWNER OR AUTBOR.PLI D REPRESENTATIVE MUST SIGN AND DATE:1111.FORM AS INDICAT'IJ). ISEE SIC IONS 2111
<br /> (a)(13)OF TIT"L.F.23-CIIAI'11R 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county an jurisdiction numbers are predetermined and can be obtained by calling the State;Board(916)227-4.303. Ibc f acdity number may lc
<br /> assigned by the local agency;however,this number must be numerical and ca-pnot contain any alphabetical characters. If the Imal agency prrefcrs
<br /> the State L3oatd to assign the facility number,please leave it blank.
<br /> IT IS Tlll: RI.SPONS11311,PFY OF TILE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION. TI[IS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED I.N. TTIE I..00AI,
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE."I,OCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDIN('3 ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO TI-EE FOIA.OWING ADDRESS. THE LOCAL AGENCY S}IOUI.D
<br /> RETAIN THE ORIG[tiALS'AND FORWARD THE YELLOW COPIES TO TETE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RLT'AI:NED BY-'TI IF TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> CIO S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PAR,AINIOUNT,CA 90723
<br /> 193
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