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►— INSTRUCTIONS FOR COMPLETING � -
<br /> ORM 91 4H
<br /> ..
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 2.5266,26257,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERA'TINC`s PERMIT,
<br /> 1, One FORM"A"shall be completed for all NEW PERMIT CHANGES or any F'ACIL.TTYiSITF:INFORMATION CHANGES,
<br /> 2. SUBMIT ONLY OINM(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 part of the application showing the locution of the USTs with respect to
<br /> buildings and landmarks,(Section 2711(a)(t1),CCR].
<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 s(Section 2711(a)(11),CCR].
<br /> TOP OF FORMS "MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the item that best describes the reason the farm is being completed,
<br /> L FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record name and address(physical location)of the underground tank(s),
<br /> NOTE-: Address MUST have a valid physical location including city,state.and zip rode,
<br /> P.O.BOX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include nearest crass street and name of the operator.
<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 OF BUSINESS OWNERSHIP(ex.CORPORATION,INDI VIDUAL,etc,).
<br /> 4, Check the appropriate box for TYPE OF BUSINESS.
<br /> S. If Facility/Site is located within an Indian reservation or other 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 /> II, PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Cornplete ail stems in this section,unless all items are the same as SECTION 1;If the same,write"SAME AS SITE"across this sedan. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> Ill,TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all itenns are the same assEcTION I;If the same,write"SAME AS SITE"across this section, Be stare
<br /> to check TANK OWNERS'TYPE box.
<br /> IV,BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(,MUST BE COMPLETED.SEE ARTICLE S,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH ANDSAFETY CODE._)
<br /> Enter your Board of Equalization(DOE)LIST storage fee account number which is required before your permit application can be processed,
<br /> Registration with the DOE will ensure that you will receive a quarterly storage fee retuni in reparring the per gallon fee due on the number of
<br /> gallons placed in your USTs. The BOE will code persons exempt from paying the storage flee so returns will not be sent. If you do not have an
<br /> account number with the EOE or if you have away questions regarding the fee or exemption,,,please call the DOE at 916-322-1669 or write to the
<br /> BOB at the following address Board of Equalization,Fuel Taxes Division,P.O,Box 942579,Sacramento,CA 14279--0001,
<br /> Y. PETROLEUM UST FINANCIAL RESPONSIBILITY(MUST"BE COMPLETED FOR PE1°F"IFC3I.;FUM t STs 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 Federal and State financial responsibility requirements.UST,.;owned by
<br /> any Federal or State agency as well as non-petroleum UST's are exempt from this requirement,
<br /> VI.LEGAL NOTIFICATION ANIS BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br /> TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST"SIGN AND BATE THE FORM AS INDICATED, (SEE SECTIONS 2711
<br /> (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,]
<br /> INSTRUCTION FOR THE LOCAL AGENCIES
<br /> The county and jurisdiction numbers are predetermined and can be obtained by catling the State Board(gib)227-4303. The facility number may
<br /> be 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 number,please leave it blank.
<br /> IT IS TETE RESPONSIBILITY OF THE LOCAL AGENCY T14AT INSPECTS THE FACILITY TO V RiFY THE ACCURACY OF THE
<br /> INFORMATION, THIS APPLICATION CANNOT BE.PROCESSED IF THE BOB ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF T14E"LOCAL AGENCY USE ONLY" INFORMATION BOX., THE LOCAL
<br /> AGENCY SHOULD RETAIN THE ORIGINAL AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br /> OWNER.
<br /> 6195
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