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z • INSTRUCTIONS FOR COMPLETING FORM "Art GFINI-I'RAL INSTRUCTIONS; � f SI FUI;0'N 2711 OF TITLF 23,.CHAPTER,16,CALIFORNIA CODE OF.REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHANTER . G?,U, TSION Q;; € (3R-41A HEAD TH ANDS,A3?ETY.CODE REQUIRE O'N(NER$TO APPLY FOR AN UST OPERATING PERMIT. ti 1. Orae FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES. f, t CiB1V{1`P C>NL O\l (1)FC)ItM"A"for a Facility/Sue,regardless of the number of tanks located at the site, 3.This form should be completed by either the PERMIT APPLICANTor the'f OCAL AGENCY UNDERGROUND'TANK INSPECTOR. _ y 4, Please type or prurt c ioarly all requcstedinfotmatiort i S. Use a hard point writing instrument,you are making 3 copies. 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 respeato buildings and landmarks[Section 2711(a)(8),CCRI. 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the application for petroleum USTs[Section 27i1-(a)(Il),CCRI. TOP OFFORM:""MARK ON LY ONE ITEM" Markan(X)hi the box next to the item that best describes the reason the form is being completed. f ] .-FACILITY/SITE I.'iFORAI AT TON&ADDRESS(MUST BE COMPLETED) 1. Record name and address(physical location)of the underground tank(s). NOTE:T Address MUST have a valid physical,location including city,state,and zip code. P.O.13OX NU\113 CRS ARE NOT ACCEPT'ABIk Ineiudc nearest cross street andpamz of the operator. _. - I 2. Non omn number must have an area code.If,the tight nor pbgt is the aortia,write"SAME"in proper location. r 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP lex.CORPORAcT1614,INDIVIDUAL,etc.). t 4. Check the appropriate box for TYPE OF BUSINESS. 5.If FacilitxJ itch Ic:at d within an Indian reservation op9thet Indian trust lands,check the box marked"YES". 6. Indicate the NUMBER of TANKS atthisSITE._ . ' 7. Record the LPA.11)#or write-"CONE".in the space provided. TY ADDRESS MUST 13L II. PRO all itcmlI tnihis sectioutp unless all i ems ar the same a&SEC'IIONN i,If the.same,write'SA;Y1E AS SITE"across this section. Be sure t Complete � to check PROPERTY OWNLKSfI1P TYPE box. r 111:'i ANN OWNEI tPbR A & f7DC2ESS{MUST BE COMPLETED), _ 4 `. Complete all'items!n Bit#-se_lion'tmless All items are the swine as SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure to check TANk C tst'fiRS�Y; PE box. IV:BOARiy OF EQUAx L-IZAI'iO)\LS'I SfORAGE•-FEE ACCOUNT NUMBER(MUST BE COMPLET"E'D.SEE ARTICLES CHAPTER 6.75,- DIVISION 20,CALIFC)Rl`tTA IIGALTH A�D SAFETY CODE.} Enter yourBoard• qu4i�miow(BOE}:UST'storageJee aecourtt mmnber which is requited before yoarpennit applicaticxt c:an he processed.. Registration with the BOO will ensure that you will receive a quarterly storage fee return in reporting the S0.(Y)6((mills)per gallon fee duc on the , E dumber of USTs. The BAE.wilt code persoaa exempt from paying the storage fee so returns will not be sent. If you do not have an account tit it brtr w4b the BOE or.if you have any questions regarding the fee or exemptions,please call the BOE at 916 322.966{3 or write to the 130E atdua fo4ow4) address Board of Equalization,Fuel;Taxes Division,P.O.Box 942879,Sacramento,CA 9.1279-0001. j' V. PETROLEUM UST FINANC IAL 1tI:SPONSIBILEY Y(MUST BE COMPLETED FOR Pl fItOLLc1NC LIST,ONI [.Y,SI.-'I;SECTIONS 2711 (a)(8) 0.1 1TL6 23,CIIA2,TER 16.CAL ORNIA CODE-OF REGULATIONS.} _ Identify the ntethuST00"l <t�te owttprandlor operator;in meeting the Federal and.State'financial responsibility rcquircutcnts.US•I'S uWned by any Inderal or State.agency as:.well as non-petroleum US'fs are exempt from this requirement. c V1.LEGAL NOTIFICATION AND TRILLING ADDRESS ` Check ONE.BOX for the address that will be used for BOTH LEGAL AND BILI F. G NOTIFICATTO\S. TANK OWNH*b AUT1j` PIPRESENUTIVVIRUStSIGN•AAD DATE TIE FORM AS I DI.C:ATIsD. [.S1.E S C TIONS 2711 -(AX13')OFTIY'M23'fi: -rjR16,CA11FORNIACODROFREGULAfTIONS.) IINS•IRUCTION FOR THEIbCA.G;:AGI.FIOIES The county an Jurisdiction nu bars are predetermined and`canbe obtained by calling the State Board(916)227-1303. 1'hc facility number may he ass fi ned b_!the Ttxal` w r*Wer,t6iiium t4 must Ue trumedc.d.ind cannot contain any alphabetical characters If the local agency Prefers the State _ wBo_a;rd blank. _IT 1S.-ir1L'-ItI:?SPON'SIDtLITY OF T"11E LOCAL AGENCY THAT INSPECTS THE FACILrI'Y TO VERIFY THE ACCURACY OF THE INFORMKTION. TRIS*111 CATIONC*AiN vOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. niF LOCAL AGEhICY-IS RUSPONST".EFOl?t•'FITE.COMPI.ETION OF THE"VOCAL AGENCY USE ONLY" IN FORMATION BOX AND FOR 6 FogftkDINd ONE I'ORlyli'A"AND ASSOCIATED FORM"I'mtb THE FOLLOWING ADDRESS. THE LOCAL AGENICY S14OULD RETAIN 711E ORJGINALS`ANITFORWARD THE YELLOW COPIES fO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE RETAlttii. Y-THF s ' STATEOF CAI..IFORNIA .._ r a STATE WATER RESOURCES CONTROL BOARD C10",k.,W E.P.S. s ' DATA I'ROCESSIING CEN11sR _1 t° s 11,0.BOX 527 'r I'ARA'sIOLN I,CA 90723 - I