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INSTRUCTIONS FOR COMPLETING FORM "At'
<br /> GENERAL INSTRUCTIONS:
<br /> SIEC 11ON 2711 OF TFILE 23,CIIAPTTER 16,CALIFORNIA CODE.OF REGULATIONS IONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER .
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE RrQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERNUT CI IANGES or any FACILITYISIITE INFORMATION CHANGES.
<br /> 2. SUBMIT 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 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 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 as part of the
<br /> application for petroleum USTs(Section 2711(a)(11),CCR}.
<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 form is being completed.
<br /> I. FACILITY/SITE INFORMAITON&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 zip code.
<br /> P.O,BOX NUMBERS ARE NOT ACCL FFABLE.
<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 131-;SLNESS OWNERSHIP(ex.CORPORATION,LNDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for-TYPE OF BI)SINESS
<br /> 5. If Facility/Site 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 E.P.A.ID 4 or write"NONE."in the space provided.
<br /> IT. PROPERTY OWNER INFORMA11ON&ADDRESS(MUSTBIE COMPLETED)
<br /> Complete all items ill this section,unless all items are the same as SECTION 1;If the same,write"SAME.AS SITE"across this section. fie sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> III:TANK OWNER.ENFORMATION&ADDRL?SS(MUSTBL's COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION 1;If die same,write"SAME AS SITE"across this section. Be sure
<br /> to checkTANK OWNERS TYPE;box.
<br /> IV,BOARD Oh EQUALIZATION L'STSTORAGE ERIE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA I113ALTI I AND SAFETY CODE.)
<br /> Inter yr>ur Board of E iu:iz:iiion(WI")LST storage fee account number which is required before your pennit application can be,processed.
<br /> Registration With the BOE will VISurc that you will receive a quarterly storage fee return in reporting the 50.(X)6((rnilL)pergailon fee due on the
<br /> number of gallons placed in your f:ST"s. The BOL,will crude persons exempt from paying the storage fee so returns will riot be,sc€it. If you do not
<br /> have an account number)�ith Clic.110E or if you have any questions rcearding the fee or exemptions,please call the B01-at 916 322.99619 or write
<br /> to the B01:at the following address Board of E'qualixation,Fuel.Taxes Division,P.O.Box 942879,Sacramento,CA 94279 0001,
<br /> V. PE'I'ROLF�L.\I LS 1 l.l:\A tiCIAI,RESPONSIBILITY(MUST m..COMPI..F TED FOR PETROL T M UST's ONLY,SI ZE SECT IONS 2711(a)(8)
<br /> OFTITLE 23,Cl rAP TREK 1(,,CALIFORNIA CODE 01,REX4ULAT IONS.)
<br /> Ide i-tfy the by the owner and,/or operaior,in niecting the Federal and State financial responsibility r q€€ircnit;nts.USTs owned by
<br /> any F:doral or State a4;;Mcy as wci.l•as non-petroleum USP;;are exempt'front this requirement.
<br /> VI.LEGAL NO"IIFICATION AND BILLING ADDRESS
<br /> Check ON'IE BOX for the address that will be used for BOTH LEGAL.AND BIL LL\G NOTIFICATIONS.
<br /> TANK OWNER OR.AUTHORI ED REPRESENTATIVE MUST SIGN AND DATE TIIIE FOR.1M AS INDICATED. (SLF.SECTIONS 2711
<br /> (a)(13)OF TITCH,23 CHAPTER ER 16,CALIFORNIA CODE OFREGULATIONS.]
<br /> INSTRUCTION FOR THE.LOCAL.AGENCIES
<br /> The county an jurisdiction nurntxrs are predetermined and can be obtained by calling the State Board(916)227-4303. Tfie facility numbermay be
<br /> assigned by the local agency;however,this member must be numerical and cannot contain any alphabetical characters. Ifthe local.agency prefers
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS'I'lilE RESPONSIBILITY OF T111.E LOCAL AGENCY THAT INSPECTS T1iE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> IINFORMATIO.N. T HIS APPLICATION CANNOT BE PROCESSED IF THE 130E ACCOUNT NUMBER IS NOT FILLET?IN. THE LOCAL
<br /> AGENCY IS Rl.'SPONSIBLE' FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWLtiG AD'DRIESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN T IIE ORIC:r1NALS AND FORWARD THE YELLOW COPIES TO TIIE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RITAI.NE0 BY TIFFi TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RiiSOURCES CONTROL BOARD
<br /> C{O S.W.E.E.P.S.
<br /> DATA PROCESS11\G CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> 3 93 FOR0120P,i
<br />
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