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<br /> INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TI;I F'2 S,CHAFT Fri 16,C.,ALJF0R,FILA CC)i)R OF REGULATIONS AND SECTIONS?5286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION"20,CALIFORNIA I-II'.ALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING,ING,, EgI".,iZMI T.
<br /> 1, One FORM"A"shall be completed for aI[NEW FIaRN41T CHANGES S 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 farm should be completed by either the PERMIT APPLICANT or the LOCAL,AGENCY UNDERGROUND TANTO INSPECTOR,
<br /> 4. Please type or print cl€arly i gciested informath,n,
<br /> 5. LFse a hid point writing instrument,you are making 3 copies.
<br /> 6. Tank owner mast submit a facility plot plan to the l€sc tial as enr y tLs4on of the:application shcswing.lbe LocathQjX
<br /> gf tbt_j ,,with resTseci tl
<br /> buildings and landmarks[Section 7771 (a)(S),CCR],
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility regtairenreats to the local agency as part Fof the
<br /> application for petroleum UST,;[Section 2711 (a)(t 1),CCR].
<br /> TOP OF FORNIi"MARK ONLY ON",-:ITI:'I l"
<br /> Mark,an(.N)in the;box next Ne the hen that best describes the reason the form is bating completed,
<br /> T. FACILITY/SITE FACILITY/SITEINFORMATION& Vii:°Ft:",P ESS(MUST BE COMPLETED)
<br /> D)
<br /> I. Record narne and ad Tres,(physical location)of the underground t ak(s).
<br /> NOTE; Address MUST hav a valid physical hicaeion includini;city.stat,anal zap code,
<br /> RO,BOX NUMBERS ARE NOT"AC Cl:r'TABLE,
<br /> Include nearest cross street and narne of the operator.
<br /> 2. Phone muad er must have an area codas, If the taa<tltt mart ber is the<sanae as .c"SAME in proper location.
<br /> 3, Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex.C O', OR
<br /> R A'TION,INDIVIDUAL etc,).
<br /> 4. Check the appropriate box for TYPE
<br /> F.OF B tSINES&
<br /> S. If racilltyfSite is located within an Indum reservation or other Indian trust I yids,check the box marked"YRS"
<br /> 6. Indicate the NL,4IBER of TANKS at this SITE,
<br /> 7. Record the E,p.A.,If)#or write"NONE"in the space provide-d,
<br /> II, PROPERTY OWNER INF( �5.1"IIt.."` &ADDRESS(MU-ST B CC}MI'LETED)
<br /> Crunplo t.,'ail item's in this section,,.,<I,ss a 1,.c n,,...c tl to 4 .arsc SECTION=N I;If.lie samw,write r<S STB AS SITE`aa€rosy,this section,NBe sure
<br /> to check PROPERTY
<br /> Calx NIaRS ia.s TYPEF:x.
<br /> III,TANK C)'3r'NE IN ":sllMAT:hD I xti,alz:;h'SS(MI:! T Vii:COMPLETECOMPLETED)Coratp+ei all items in tlta taw.=_on,wfless aft sterns arc th saune as SECTION I;If the saws,,,vrite"SAME AS SITE'icross this:secrion. Be sure
<br /> to check TANK OWNERS TYPE box. _. _ .
<br /> IV,BOARD OF EQUALIZATION UST STORAGE FET'ACCOUNT NUMBER(MUST BE COMPLETED,SEE ARTICLE,5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AN S AF TY CODE.)
<br /> Mater your Board of Equalization(BOE)UST storage fee account number which is required before your permit application can be proce;sscd,'__
<br /> Registration with the.ROE will entiu,e mat you will receive a quarterly storage fee return in reporting the per gallon fee due on the member of
<br /> gallons placed in your USTs. The BOE will code per,uats exempt frorr paying the storage fee so returns will not:be sent. If yoga do not have an
<br /> account number with the BOE or ifyou Eta e any°questions regarding the fie or exemptions,please call the BOE it 916-31-1-9669 or write to the
<br /> BOE at the following address Board of Equ a€rzafion,Fuel Taxes Division,RO.Box 942879,Sacramento,CA caa277_C7(=01.
<br /> V, PETROLEUM UST"FINANCIAL.RL SPONSIBI ,ITY(TvI17STLTE COMPLETED FOR PETROLEUM USTs ONLY,SEB SECTIONS 2711 (a){11)
<br /> OFTITLE ITLR 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,)
<br /> Identify the meth rk's)used by the owner andior operator,its tstecting the Federal and State financial responsibility requirements.USTs owned by
<br /> any Federal or State agency as well as non a irolenna USTs are exempt from this requirement.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> S
<br /> Check ONE BOX for the zr a:r€ss t,aat will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK OWI ER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICAT 11 [SEE SECTIONS 2711
<br /> tta(rit3 of TITLET 23 CHAPTER tat,C.ALH ORNIA CODEOF REGULATIONS,]
<br /> INSTRUCTION FOR THE LOCAL.AGENCIES
<br /> The county andjurisdiction nambers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number may
<br /> be assigns crhy the local agsmcv;however,this number must be numerical and cannot contain any;alphabetical characters, If the.local agency
<br /> prefers the State Board to assign th ('"cality nest ea,please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE IACILI'`I°a' TO Y'B.R!i-Y `tsar: ACCURACY OF THE
<br /> INF(',)R 4,kT1,ON THIS, PPLI .,s=SIN t,.C, `"O ISI',PPOC,€ CSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL
<br /> k,3 L 3 IS 1 t,O 'S. 4L.T: ,' s3gH11, 'a.()CA.L At:ENt<`Y USEONLY" INFRM N OX. TFT LOCAL
<br /> <<,T.CE�:g, r `'3-'. ,Fe,..:i, s f t AIN I . .,1`I,'tT,
<br /> AND aA:a.1. 1 FC° r"s!T'IF;'`s. TFIL 1='I';�$s. C.,C?1�$Y S`['I'C'? I.,I3 FI`L: RETAINED LIT' "IT-IF.T"A ..
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