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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 1711 OF TIT'LB 23,CIIAPTFR 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISI6N-20,CALIFORNIA IIEAiT'ji AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERmyr.
<br /> 1, One FORM"A"shall be completed for all NEW PERNUTCHANGES or any l7A(-iL.1'i�/S!'I'I'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 TNSPEI=C
<br /> 4. Please type or print clearly all requested itifoinnation.
<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 part of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711 (a)(8),CCRI.
<br /> 7. Tank owner must submit documentation Showing compliance with state financial responsibility requirements to the local agency is pari of the
<br /> application for petroleum USTs[Section 2711 (a)(11),CCRJ.
<br /> TOP OF FORM:"MARK ONLY ONE ITE'.4"
<br /> Mark an(X)in the box next to the item that Nest describes the reason the form is being completed.
<br /> L FACILITY/SITE LNFOR-MATION&ADDRESS(MUST BE COMPLETED)
<br /> L Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address MUST have a valid physicai location including city,state,and zip code.
<br /> RO,BOX NUMBERS ARE NOTACCRI"I'ABLE,
<br /> Include nearest cross street and name of the operamn
<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 Olt BUSINESS OWNERSHIP(ex,CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSLNI;SS.
<br /> 5. If Facility/Site is located within an Indian reservation or other Indian trust lands,check the box marked"YE-s".
<br /> 6. Indicate the NUMBER of TANKS at this SITE.
<br /> 7. Record the E.P.A.ID 4 or write"NONE"in the space provided.
<br /> 11. PROPERTY OWNER INFORMATION&ADDRESS(1USTBE,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 sum
<br /> to check PROPERTY OWNERSHIP TYPE,,box.
<br /> 1.11.TANK OWNER INFORMATION&ADDREISS(MUST'BI 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 sectiom Be sure
<br /> to check TANK OWNERS TYPE box.
<br /> IV.BOARD 01,EQUALIZATION USF 1 TiE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHApTuR 6.75,
<br /> DIVISION 20,CALIFORNIA 111-1-ALT11 AND SAFETY CODE.)
<br /> Ellicl your Board of 17clualization(B01")UST storage fee account number which is required before your punnit application can be processed.
<br /> Registration with the BOE will ensure that you wilt receive a quarterly storage fee return in reporting the 50.006(61nills)per gallon fee due on the
<br /> number of galai>ns placed in yc,ur tiS'1's. The BOF will code persons exempt from paying the storage fee So returns will not be sent. Ifyoudonot
<br /> have an account nurnbcr with the 130E or if you have any questions regarding the fee or exemptions,please call the B01,at 910 322 9069 or
<br /> to the 13011 at Llic following ad:rens Board of Equalization,Fuel Taxes Division,11.0.Box 942879,Sacramento,CA 94279-0001
<br /> V. PEIROLF.UM LI'Sl'l-.I.NA.\C'IAI,R[,"S!)O.T\SIBII,I'I'Y(MUST BE COMPI.F.-FED FOR PEI-HwLEUNI USTs ONLY,SL,I SLCTION'S 2711 (a)(8)
<br /> OF TIT 23,C'L'AP 1'1,--,R 16,CALIFORNIA CODE OF REGuLATIONS.)
<br /> IdLittify the nictilcx](s)used by The wmicr and/or operator,in nutting the Federal and State financiat responsibdiiv requin:,rn(v,4 l,STs otrno,!by
<br /> any Federal or State agency as well as nori-petroleum 1_;'ST,,are exempt from this rcquircrncnt.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOI I FICATIONS.
<br /> TANK OWNER OR.AUTHORIZED REPRESENTATIVE,MUST SIGN AND DATE THEFORM AS INDICA]PD. (SF! S[X-TTONS2711
<br /> (a)(13)OF'il'I'I,E23(.'IIAI)-I'I:R 16,CAI JFORNJ A CODE OF REGULATIONS]
<br /> INSTRUCTION FOR TIII-,',LOCAL AGENCIES
<br /> The county an jurisdiction numbers are predetermined arid can be obtained by calling the State Board(916)227-4303. The facility mrinber 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 the facility number,please leave it blank.
<br /> IT IS THE RESPONSIBILITY OFTIII.,, LOCAL AGENCY IIIAT INSPECTS THE FACIl,FIY TO VERIFY THE ACCURACY OF THE
<br /> LNFORMATION. '1111S APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THELOC*AI
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RE'T'AIN THE 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 /> CIO S.W.E.E.P.S.
<br /> DATA PROCESSLNG CENM
<br /> P.O.BOX 527
<br /> PARANIOUNIT,CA 90723
<br /> 3193 FOR012DRI
<br />
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