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INSTRUCTIONS FOR COMPLETING FORM "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION2711 OF TITLE 23,CHAPTT:R 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY 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 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. "rank 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),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 USTs[Section 2711(a)(1.1),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 fort is being completed.
<br /> I. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETE,D)
<br /> I. 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 ACCFlyfABLF.
<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 T"YPI:?OF BUSINESS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> S. If Facility/Site is located within att Indian reservation or other Indian trust lands,check the box marked"YES".
<br /> 6. Indicate the NUMBER of TANKS at this STFE.
<br /> T Record the E.P.A.1I)4 or write"NONE."in the space provided.
<br /> II. PROPERTY OWNER INFORMATION&ADDRESS('MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION l;If the same,write"SAME AS SrEE"across this section.n. Be sure
<br /> to check PROPER'T'Y OW:NERSIMI TYPE box.
<br /> III.TANK OWNER INFORMATION&ADDRESS(1Mt.1S7'BE COMPLLT'ED)
<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 TANK OWNERS TYPE box.
<br /> IV.BOARD Olt E'QLAI.IZATION UST SI OXAG,13 Ff.-F ACCOL;NT NUMBER(MUSTBE COMPLETED.SEE ARTICLE5,CHAPTER 6.75,
<br /> D VISION 20,CALIFORNIA HEALTH AND SAFETY CODE.)
<br /> Italtcr your Board of t 4-t,:ia anion(1301:)UST storage;fee account.number which is required before your pennit application cart be processed,
<br /> Re,8koation a th the 130E will vst.:e that you will receive,a quarterly storage fee return in reporting the S0.W6(irnills)per gallon fee due on the
<br /> number of gallon.,placed in yoar I lST`s. Ihc 130E will code lxarsons exerr)pt front paying the storage fee so returns will not be,sent, if you dei no
<br /> have an account number with trio 1301"or if you have any questions regarding the.fee or exemptions,plcasv call tine BOE at 916 322-9669 or write
<br /> to the 130E at the foitowing address Board of Equalization,Fuel Taxes Division,P.O.Box 942879 Sacr:uncnto,CA 9-1279-0001,
<br /> V. PE"ITtCIl 1�.t.;Yt LSI'FIN ANC! RI S!IONS I23IL.IT'Y(.must,BE COMPI.-E-1 ED FOR PF IROLEC til USTs ONLY,SI,I.SEC]IONS 2711 (3)(8)
<br /> OF TITLE 23,Cl tAPTLR 16,CAI-IFORNIA CODES OF REGLJ-LATIONS.)
<br /> Identify the mcthcxl(c)us rd by the owner andlor operator,in meeting the Federal and State financial responsibility r<,,uucrrrent,.l STs kn�ncd by
<br /> any Fedcral.or Stjte ag,;ncy as well as non-petroleum USTs areexetrtpt from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONL I30X for the address that.will be used for BOTH LEGAL AND BILLING NOTII'IC,11ON;S. _
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE;MUST SIGN AND DATE THE FORM AS INDICATEM. l,SHE SEC TIONS 2''1 i
<br /> (a)(13)OF TRITE,23 CHAPTER 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)227-4303. The facility number may 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 die facility number,please.leave it blank.
<br /> IT IS'I'Hf RESPONSIBILITY OF TIIE LOCAL.AGENCY THAT INSPECTS TIIE FACILITY TO VERIFY TILE ACCURACY OF THE
<br /> LNFOR_yIATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. 11IE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COiMPLETION OF THE "L.00AL. AGENCY USE ONLY"INFORMATION BOX AND FOR
<br /> FORWARIX.NG ONE FORM 'A"AND ASSOCIATED FORM"B"(s)T"O THE FOLLOWING ADDRESS. TIIE LOCAL AGENCY SHOULD
<br /> RETAIN"SITE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BYTHE 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 /> PARAMOUNT,CA 90723
<br /> 3;93 FORD12ORI
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