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<br /> INSTRUCTIONS FOR COMPLETING FOWNI "All
<br /> All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE QF)REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 653,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE RE($dJIRE OWNERS TO APPLY FOR AN UST OPERATING,PERMIT,
<br /> I. 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, Tank owner must submit a facility plot plan to`the`local agency as pat of the application showing the location of the LISTS with respect to
<br /> buildings and landmarks(Section 2711(a)(8),CCRJ,
<br /> 7.rrTank;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),CCR],
<br /> TOP OF FORM:"DARK 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 /> L ;FACIL.ITYISETE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> I. Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address MUST haver,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 trust 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 Cather 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 /> It. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless @I iterns are the same as SECTION I;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> IIT,TANK OWNER INFORMATION&ADDRESS(MUST BE 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 TANK.OWNERS TYPE box,
<br /> TV,BOARD OF EQUALIZATION VST"STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE,)
<br /> Enter your Board of Equalisation(BOE)UST storage fee account number which is required before your perrtoit application can be processed.
<br /> Registration with the BOB will ensure that you will receive a qua Inerly storage fee return in reporting the per.g;allon fee clue on the number of
<br /> gallons placed in your USTs. The BOE will code persons exempt'irom paying the storage fee so returns will not be sent. If you do not have an
<br /> account number with the BOB or if you have any questions regarding the fee or exemptions,please call the EOE at 916-322-9669 or write to the
<br /> + BOE,at the following,address Board ofEqualization,'Fuel Taxes Division,P,O.Box 942879,Sacramento,CA 94279-0001,
<br /> V. PETROLEUM LIST FINANCIAL RESPONSIBILITY(MUST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711(a)(I 1)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE,OF REGULATIONS.)
<br /> Identify the method(s)used by the owner and/or operator,in meeting the F=ederal and State financial respbtrsillility requirements,USTS owned by
<br /> any Federal or State agency as well as non-petroleum USTs are exempt from this requirement.
<br /> VI.LEGAL NOTIFICATION ANIS FULLING ADDRESS
<br /> Check ONh tOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK.OWNER OR AUTHORIZED REPRESENTATIVE MUST SICK`AND DATE THE FORM AS INDICATED. [SEE?SECTIONS 2711
<br /> (a)(I3)OF TITLE 23 CHAPTER 16,CALIFORNIA COLE OF REGULATIONS.)
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number may
<br /> ate assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the local agency
<br /> prefers the State Board to assign the facility slumber,please leave it blank,
<br /> IT IS TEJE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO-VERIFY THE ACCURACY OF THE
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE EOE ACCOUNT NUMBER hA-NOT FILLED IN. THE LOCAL,
<br /> AGENCY IS RESPONSIBLE FOP,THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX., THE LOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL ANIS YELLOW COPIES. THE PINK COPY SHOULD-BE-RETAINED BY THE TANK
<br /> OWNER. ..
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