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INSTRUCTIONS FOR COMPLETING FORM "All
<br /> GENERAL INSTRUCTIONS:
<br /> SEC"PION2711 OF TITIA',23,CIIAPTFR 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA IILALTII AND SAFETY CODE REQUIRE OWNERS TO APPLY I-OR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any eAC1LrI-Y/SIT1-'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 pan 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 pan of the
<br /> application for petroleum USTs{Section 2711 (a)(I 1),CCR}.
<br /> TOP OF FORM:"MARK ONLY ONE IT ENI"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> 1. FACILITY/SI'Z'E 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 zip code.
<br /> P.O,BOX 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 BUSINESS 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 the NUMBER of TANKS at this SITE.
<br /> 7. Record the,E.P.A.ID#or write"NONE"in the space provided,
<br /> U. PROPERTY OWNER INFORMA110N&ADDRESS(NIUSTBE 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 PROPERTY OWNERSHIP`TYPE box.
<br /> 11.1,TANK OWNER INFORMATION&ADDRESS(MUSTBE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SF(.71-ION 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check"TANK OWNERSTY111:box.
<br /> I.V.BOARD OF Fl,,EACCOUN-T NUMBER CNIUSTBE COMPLETED.SEE ARTICLE 5,CIIAI-rER 6.75,
<br /> DIVISION 20,CALIFORNIA 112ALT11 AND SAFETY CODE.)
<br /> Enter your Board of Equalization(BOT)USI`storagefeeaccount number which is required before your pennit application can be processed.
<br /> Registration with the BOL will ensure that you will receive a quarterly storage fee return in reporting the SO.(ffi(6mills)Nr gallon fec due cla the
<br /> number of gailows phiced in your USTs. The BOE will code persons exempt from paying the storage fee so returns will not be sent. If you do wx
<br /> have an account rwnibcr with the BOF or if you have any questions regarding thC fee Or CUMpt:1011S,pleas:;Call the 1101",at 916 322-9669 or write
<br /> to the 13011 at the following address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0001
<br /> V. IlLTROLI11'1—%I LSI'I'I-El"ANCIAl.,RESPONSIBILITY(MUST 1313 CONIPLETED FOR PEIROLEUNI USTs ONLY,SEE SECTIONS 2711 (a)(li)
<br /> OFTIT11 23,Cl]AP TER 16,CAI-IFORMA CODF.OF REGULATIONS.)
<br /> ldcieify the nicibcd(s)used by the owner and/6r operator,in mckting tote Federal and State,financial responsibility requirements,IISTowned by
<br /> any Fedcial or Si.itc agency as well as,non-petroleum USTs are exempt from this requirement.
<br /> VI.LEGAL.NOTIFICATION AND BILLING ADDRESS
<br /> Check ONF"BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUT1101UZED REPRESENTATIVE MUST'SIGN AND DA' 13 FORM AS INDICATED. ISEF SECTIONS 2711
<br /> (a)(13)01-''11'1'1.1--.23CIIAl)-I'I:R 16,C'ALIFORN'IA CODE OFREGULAI'lONS.1
<br /> IN'SIRUCIION FOR TITS LOCAL AGENCIES
<br /> The county an jurisdiction nufrilers are predetermined and can be obtained by calling the State Board(916)227-4301 The facility minthermay 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 IIIATINSPECTS THE FACILITY To VERIFY THE ACCURACY OF T'HE
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE.11)CAL
<br /> AGENCY IS RE'SPONS1BLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY'* INFORMATION BOX AND FOR
<br /> FORWARDI]ti'G ONL FORM"A"AND ASSOCIATED FOR .I"B"(s)TO THE FOLLOWLNIG ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN Il lli ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINI.-Ji.)BYTIII-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 /> PARAINIOUNT,CA 90723
<br /> FOR012DR1
<br />
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