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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 27121 OF TIT LE,23,C.11APTE.R 16,CALIFORNIA CODE OF REGULATIONS AND SECTION'S 25286,25287,AND 25259 OF CHAPTER
<br /> I2 ,
<br /> 6.7,DIVISION 20,CALIFORNIA IIEA L111 AND SAFETY CODE REQUIRE C?WNFRS TO APPLY FOR AN UST OPERATING G PER .`T'.
<br /> 1. One FORA"A:"shall be completed for all NEW PERMIT CHANGES or any;-W-C ,l. CHANGES.
<br /> 2. SUBMIT ONLY O (l)FOIaM"A"for a Faci ityfSite,regardless of the number of tanks located at the site.
<br /> 3.This form should be completed by either the PERMIT APPLICANT or the L M,AI,ACL CY tJ?sIDERGROUNM TANK L,SPF , �£..:.
<br /> 4. Please type or print clearly all requested infon ation.
<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 DSTs with respect to
<br /> buildings and landmarks[Sect'sor,2711(a)(5),OCRI.
<br /> 7. Tank owner must submit documentation showing compliance with star financial responsibility mquiatsr arras is the local agellcy as,pa!l,of;he
<br /> application for ix,trolcum USTs[Section 2711(a)(,11),CCR).
<br /> TOP OF I:FORIN:"MARK ONLY ONE ITEM"
<br /> Mark an(TL)in thebox next to tire item that best describes the reason the form is being completed,
<br /> I. FACILITY/SITE INFORMATION&ADDRESS{).+LUST BECOMPLETED)
<br /> 1. Record name and address(physical location)of the underground tank(s).
<br /> NOTE: Address musT have a valid physicaz location including city,state,and zip code,
<br /> P.O,BOX NUM13l RS ARE:NOT ACCI F FABLE`.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have.an arra axle. 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,IN'DIVI UAL,etc.).
<br /> 4. Check.the;appropriate box for TYPE€F t3LS E;SS.
<br /> 5, If Facility/Site is located within an Indian resenradon or oilier Indian trust lands,cheep the box marked"YES".
<br /> 6. Indicate the NUMBER of TA'ILS at this SITE.
<br /> 7. Record the ,P.A.ID 4 or urate"-4£)iF;"in the space provided,
<br /> II; PROPERTY OWN ,R II�I�£�FZ'�SF�`I'.F£1N&ADDRESS(NIUS"I'DE OMPL;"t'ED)
<br /> Complete all items in this section,unless all items are the sante as SEICII£) I;If the same,w t t"SAME,AS SITE"acnnr s this so,,-,tion. Be sure
<br /> to check PROPERTY OWNLRSHIP TYPE box.
<br /> Tit,TATFL(5'~a'NE l�;It'O NIA,"10-N A77DRT:SS
<br /> Complete at1£testis in this section,unless all steams are thesame as SECTION l;If r.1z...carne,wr,;.c"SAME A-S SI iz."across this sec€ioc, Re stain
<br /> to the k"T k,{)WN"ERS 7`YPE box.
<br /> IV,BOARD Ol,'I(Ql.,AlI,,IZA';'10,\L'S"4'S'l-ORA(aE FEE AC,t.:t,)Lil+T NCIM13E (NIUS'l BE£"C.)M}"LE I D,SLE,ARTICLE 5,(IIIAj--rl-R6.7.5,
<br /> DIVISION 20,CALIFORNIA(;A I'II AL'I Fl AND SAFETY COD L.)
<br /> lintesyour C3oH,d 1af.rl .,.zxitrn(I301:)UST storage fee aceot:m number which as rtea.rob&X-Sore your la:.r art apF ae«tctrs caw,Ix"
<br /> B01" you"rill rece;se a starterly= c r age I:e�," r,turn in o ing ihc,� � "
<br /> Regi�t.atrcat>£Lal=,yi 33t?zs wd!ea;su€c that 5" q " err " ilk I °gAl.,,,
<br /> r
<br /> r;:i ntrG ra'g;l;t,>zi,1.1«ceI tri y"",,ir L S'I'S, 111v B01 will code p rsons cxemipt zrarn a l s.g rt. stomp,i_. v H r z ix, f'v , o not
<br /> have an a,:c :,a.nuln 4rt,r with tate BOE or if you have ally questions oga,tang t!.z f_u or,�x .atat.,,<,,a a .r;� 01,.,",llc'at.3. ,its 9W,19 o
<br /> to the II()h at zt.x.t9u,oss ant,,a I<#rcaa s3us:r;d of Equalization,Fuel Tars Division,I'£5. 3>x.941N'79„;� ,r�,�, <;.,a,CA 9 41,-`,'alfl�?-
<br /> V, PETROLEUM F S t'ITNA oC'IAL RF:°sl'£J'aSIF3ILITY(MUST 1 E£ONIPL ED T°cl,l t- ..:ONLY,,S i SEC 1110 's e E i u);51
<br /> t11t..I'Fi'L,,�:?,Cita]'1'L:h 1ta,C;.�L,,LFtC)Its;11aC.C)I)t<£}3�L'?a£stfl.aA'CICJ� .)
<br /> Id.,,i•.;fy the rrt„t,nx?Ctil.tas.,tl Ery slits tasssaer aatat/car operator,in riac,ttng tlaeF edrtal znd SPata r...v,...i r sr,,>rs:,al,,t=}r� ,�,t..r, ,a}=.s_,.,a 1>,_- ,gid by
<br /> any Fedctat azar Stats aat„ r.cy as well as non-pvol:eusaa US`Ts are exempt from this rc,,quaotlnent.
<br /> VI,LEGAL'NOTIFICATION IC A"t ION."ND PILLING A[:3I113I SS
<br /> Cheek ONE BOX ft)r the address that will be used for F3£lTH LEGAL AND F3T1_1,NG,A'0I ra i CATION,3,
<br /> TANK OWNER OR.AUTHORIZED REPRESENTATIVE.MUST SIGN AND DA'I lu THE I•ORM AS INDI A l'ED, IS , �- (,l.t.'_:. 2`711
<br /> (a)(I3)OF TI111,23 CIIAPThR 16,CAIIFat3 aoCA CODE(7F REGULATIONS.]
<br /> INSTRUCTION N FO 'I`HE,LOCAL AGEINCIES
<br /> The county an jurisdiction ntambers are predetermined and can be olstained by calling the State Board(916)227-4301 Thr facility nurnbc.r may lac:
<br /> assigned by the local agency;however,this number must be nusrteri:cal and cannot contain any alph:al:aetical charactcrs. If the local agency prefers
<br /> the State Board to assign the facility number,please leaveit blank
<br /> IT IS THE REISPONSIl3II,TY OF THE LOCAL AGENCY'C"LEA"T`INSPECTS THE FAC3.I,T't'Y TO VERIFY THE ACCURACY OF'ITIE
<br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BOF ACCOUNT NT lSt;MBER IS NOT FILLED IN, "I'IIE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY' INFORMATION BOX AND 3`O
<br /> FORWARDING ONE FORM„A„ANIS ASSOCIATED FORM'B"(s)'ICT THE T°£)C,F.()WTNG ADDRESS. THE'LOCAL AGENCY SHOULD
<br /> R;T AIi t HE t)l IGIALS AND FORWARD THE YELLOW COPIESTO'TTIE FOLLOWLNG ADDRESS.THE PINK COPY SHOULD BE
<br /> RE'TAINI;D 13Y'1'llE TANK OWNER.
<br /> STATE Cal,CAL1I ORIN"IA
<br /> STATE WAT' IFCE; 'ULC ES CONTROL BOARD
<br /> C/0 S,A'r.T..I:.P. .
<br /> DATA PROCESSING CENTER
<br /> a: P.G.BOX 527
<br /> PARAMOUNT,CA 90723'
<br /> 3?93FOR0120RI
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