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INSTRUCTIONS FOR C1 r "All
<br />GENERAL INSTRUCTIONS:
<br />SECTION 2711 OF TITLE- 23, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25285, 25287,, AND 2.5289 OF C"FIAPTER
<br />6.7, DIVISION 20, CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PEP -MIT.
<br />1. One FORM A" shall be completed for all N'EW PERMITCHANGES or any FACILITY/SITE INFORMATION CIiANGES,
<br />2, SUBMIT ONLY ONE (1) FORM "A" for a Facility/Site , regardless of the number of tanks Ioc aced at the site.
<br />3: This, form ftnild be canpleted by either the PERMIT APPLICANT or the LOCAL, AG NCY UNDERGROUNDTANK AN INSPE£"ice t
<br />4. Please type or print clearly all requested information,
<br />S, Use a harm point writing instrument, you are making 3 copies.
<br />6. Tank owner must submit a facility plot plan to the Racal agency as part of the application showing the location of the UST, with respect to
<br />buildings and landinarks [Section 2711 (a)(8), CCRI,
<br />7. Tank owner must. submit documentation showing compliance with state, financial responsibility requirements to the local agency as part of the
<br />application for petroleum UST,
<br />[Section 2711(a)(11), CCRJ,
<br />TOP OF FORM: "NTARK ONLY ONE I ENT'
<br />Nark art (X) In the Box next to the item that best describes the reason the fine is being completed.
<br />I. FAC'IIJTY/SEl'E INFORMATION k: ADDRESS (1slUST BE COMPLETED)
<br />1. Record name and address (physical 'location) of the underground tan (s).
<br />NOTE: Address MUST have a valid physical location including city, state, and zip code.
<br />P,O. 13OX NUMBERS ARE NOT ACCEFFABLE.
<br />Include, nearest cross street and name ofthe operator.
<br />2. Phone number must have an area pode. if the night number is the same, writ. „SANTE" in proper location,
<br />3. :heck the appropriate box for T�YI'ii OF BUSINESS I')W'NI,S' SHIP (ex. CCIRPOIkATIC)N iISDIVIQUAL., etc.).
<br />4. £`_:het k the appropriate box for TYPE OF BUSINESS.
<br />5. If I acilhylSn , is located within art Indian reservation or other Indian trust lands, chick the box malked,"YES".
<br />5. indicate Y.he NUMBER of TANKS at this SITE.
<br />T Record the E.P.A, 11) 4 or write "NONE" in the space: provided.
<br />TL PROPERTY O)NNER INFORMATION & ADDRESS (MUST BE COMPLETED)
<br />Complete all items ion thiq section, unless all itctaE are the same as SLCT90N 1, If the same, write "SASNaF, AS Shl`E" across thio section, Be sure
<br />to check PROPER"I`Y OWNERSHIP TYPE: tea:
<br />IIL 1"ItNK OWNER INFORMATION & ADDRESS (�iL;S i` tit C i3�3' ;I l FUj
<br />Complete all items in this section, unless all items are the same as SEC CION 1; If the a ame, write `SAMEAS Sl IT"' across this section, Be sure,
<br />to checkTANS, OWNERSTYPE. bcax;
<br />IVBOARD OI E', UAI..TZATION C ; I` S"a 01tA I' FiilI' ACC OL7 'N -i NUMBER (MI -ST BE: CONIPLET E17- SEE ARTICI..H, 5, CISA I 'R, 6.75,
<br />DIVISION 20, CALIFORNIA 11E>AL-1.1I AND SAhI:TY COi3i--.)
<br />Filer ywir Board of Frju aaz.at a x. (130it,) UST storage fee account. mealier which is re <;aa:rad b :fcaru yc;tar lx. r nit alslsliti, ti< a c:aaa bt asteaec:.,st°d,
<br />Ii 1,.stration e:ih the 1301: will ensure that you will receive a quarterly storage fee return ora rel;ostaaa„ the S0JX)0 (coins) pv; LazL�a ;Ice done: on the
<br />r„.a nlse.r of gallons p7.a,:ed to your LS"1's. The I301, will z_rria arsons ea.r.itf t arz paying q, the staa.asc tie six t,,,tarrls a , ; ,.nt_ if'}<a. ;ate not
<br />have oat acco,,l t tai,);€ ct, wit}, tho Belli or if you have ally qucsuoms r garuing the fee or „x'ump! ion. , g ham,; Call this BOE al S?t. 122-;(69 ;}r eerier.;
<br />to the 130E at tzar following address hoard of Ecluali ratiou, Fuel,laxt, Division, 11,0. Box 94,28f S, .,.. nlo; CA 91s 79 0001.
<br />V1 PIi"11ZOIl;i: L,51-' at` ANC.IA!, Ill.tiE't' NSIIIH,ITY Q IUS'i BE COMPLE"! e)It PI"lROTIZr,t. l L;S'l's ONLYSEE Sll,',-;'! KYN 2-711 a(S)
<br />OF -11,11-1 23, C.I I APTE' ' E 16, CALIFORNIA OR IA C ODE 01, IZFiGLR,ATIONS,}
<br />n
<br />idet,>ny alae za_cthocir s, ta,€,n by the owner aaautoro,et<etu�r,rn mv.zsarg tile Federal and ,4t+, k ,aF.r al ac_;arir.al i1iry r,: si_.r_,x:��Et , a. `� t s a <nCd ,
<br />any i c=lcrai of State; aa;etacy as wed a, non petrol°.:wilt USTS alai exen.pt from dais requircnwnt.
<br />VI, LE'GAI. NtT` IFICA°IION AND BI T.I:NG ADDRESS
<br />Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NO. IFWA.IO��S.
<br />TANK OWNER OR, AU'E'HORI EDREIlRF.,SENTAT`IVE, li'STSIG.NANT) I-i,�'1E IA.?FOR,, ASINT)IC AL:
<br />(a)(13) OF 1 TLE' 23 C:11AP`1'ER 16„CA 11AORNIA COLE OF REGUL AT""IONS.'i
<br />INSIRUC'E1ON FOR THE LOCALAtill,.NCII:S
<br />The county an jurisdiction millers are predetermined and call be obtained by calling the St aue Board (u 16) 22 4303. The_a- do , nurnlicrnciy be
<br />assignees by the local ,ag:.triy: however, this number must he numerical Arid cannot contain any a g haba4,iicai characters_ If the local agency Tnrufcrs
<br />the Stat. Hoard to assign the facility number, please leave it blank.
<br />IT IS THE RESPONSIBILITY OFTHE LOCAL AGENCY THATINSPECTS THE FACILrf'Y 'TO VERIFY TIIi-; ACC UIRACY OF THE
<br />INFOR27VIA' TON. THIS APPLICATION CANNOT BE PROCESSED IF THL BOE' ACCOUNT NUMBERIS NOT111.1,M) INC. THE LOC:AL
<br />AGENCY IS Rll,'SP ONSIBLE FOR THE CONIPL%TION OF THE "LOCAL, AGENCY CY USE ONLY" INFORMATION BOX AND FOR
<br />FORAVAIC=) NG E2,` E FORIST "A” AND ASSOCIATED FORM "B"(s) TO THE FOLLOWLNG ADDRESS, TUE LOCAL, AGENCY SHOULD
<br />Ri:T,-AIN THE ORJGiNAI S ANIS FORWARD THE YELLOW COPIES TO THE FOLLO LNG ADDRESS. THE PINK COPY SHOULD BE
<br />RETA _NI,A) BY pili" TANK OWNER,
<br />STATE OF CALIFORNIA
<br />STATE WX111RRESOURCES CONTROL BOARD
<br />CIO S.W,E.E.P.S.
<br />DATA PROCESSING CENTER
<br />P.O. BOX 527
<br />PARAMOUNT, CA 90723
<br />3193 FOR012ORI
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