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INSTRUCOQNS FOA COMPLETING R04 "AIV
<br />GENERAL INSTRUCTIONS:
<br />SECTION2711 OFTITLE. 23, CIIAVITR 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286, 25287, AND 25289 OF CHAPTER
<br />6.7, DIVISION 20, CAI.1l`OR-\IA HLAumAND SAkETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br />1. One FORINI "A" shall be completed for all NEW PEIQWT CHANGES or any FACIIATY/SITE INFORMATION CHANGES.
<br />2. SUBMIT ONLY ONE: (1) FORM "A" for a Facility/Site, regardless orthe number of tanks located at the site.
<br />1 This fonn should be, completed by either the PF*R.'vllT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR.
<br />4. ],lease 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 location of the USTS with respect to
<br />buildings and landmarks [Section 2711 (a)(8), CCR].
<br />7. Tank owner mw, submit documentation showing compliance with state financial responsibility requirements to the I(xAd agency as part of the
<br />application for petroleum USTs [Section 2711 (a)(I 1), CCRI.
<br />TOP OF FORM: "MARK ONLY ONE rrL.M"
<br />Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br />I. FACILITY/SITE INFORMATION& ADDRESS (MUST BE COMPLETED)
<br />1. Record narne and address (physical location) of the underground tank(s).
<br />NOTE: Address MUST have a valid physical location including city, state, and zip code.
<br />P.O. I30X NUMBERS ARE NOT ACCE-PTA1311F.
<br />Include nearest cross 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 TYPEOF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, 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. 11) # or write "NON E- in the space provided.
<br />T.I. IIROPI-'IITYOYv'NL,,RLN'I:ORMA'IION&ADDRESS (-"IUSTBI.�-,COMPI-r-TED)
<br />Complete all items in this section, unless all items are the same as SE.C711ON 1; If the same, write "SAME AS SITE" across this section. Be sure
<br />to check PROPERTY OWNF„RS11111'1 YPI`box.
<br />1:11. TANK OWNER INFORM ATlO\ & ADDRI�SS (MUST BE COMPI.,FTED)
<br />Cornpleic all iteins in this section, unless all items are the same as SECTION 1; If the same, write -SANIF AS SITE" across this section. Be sure
<br />e I
<br />to check TANK OW NI RSIA'I'E box.
<br />TV,130ARI)Oi�lQUAI.-"ZA'1'10\I S I'S 10RAGE FEE ACC 'NT NUMBER (MUST 1312 CO.MIPLE'lTD. SEF ARTICLE 3, CIIAllTVR (),75,
<br />DIVISION 20, CALIFORNIA 111'Al-T711 AND SAFI:IYCODI,-)
<br />Firicr yc,,ur Board of I'ROF)IUS Fs!ornc frcacclyurtt nurnber0-Jeh isrc,,i.imd h1,40TC, YOUTTxninit appfic-aiion can li. pnicess'ed.
<br />Rqtnition Ntith lIlv BOE lh,lt you ,vdl r; 'eivQa quarterly st,mlyC fee Y-ClUrn in reponing the S0,'J(6 floai,ilk) pci gallon Ice due' on die
<br />nun -incl of gaikn�)!r�,cd in �our U'S The BOE A'It code persons exempt front paying the stor�Agc fire so rvtur!l� �kfll Trut bus !f you do not
<br />'"
<br />have, an w..,liOE I if voli ha%e'arty questions Tcg"irding Ihe Eco m please, call ,h,; 1301�1 at (#Io 322 9009 or wrilc
<br />to tho BOE -I, the zAJJI�— Iii !!.-Jl c,f L yuai.rittion, Fuel Taxes Division, 11.0. 3ox er f 5?9, Sacialrento, CA 9-12,79 ('001.
<br />V.
<br />OFTIT LE, 23, Chir VITR 16, CAl-IFORNIA CODL 0FR;:(A1'l-ATIONS.)
<br />Identify the weth<xl(s) used by the owzw.r and/or operator, in meeting the Federal and State financial rcqoire-lilctits. LIST!, (-, ;,cd by
<br />any Fedcral or St,iic agcr,.,;y as well as non petrolzurn UST's are exempt from this requirement.
<br />VT. LEGAL NO'l 111CATIO.N AND BILLING ADDRESS
<br />Check ONE BOX for the :IdIl, ess that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS,
<br />TANK OWNER OR AUTt I OR MED RE .11RESENTATIV S MI STSIGN AND DATE TI IE FORM AS INDICA CI D. ISI: E' SI;( -J IONS 2"1I I
<br />(a)(13) 01' TITLE 23 CIIAPI'E'R 16, CALIFORNIA CODE 0',- REGULATIONS.]
<br />1NS'lRUC'IION FOR '11 LF, LOCAL AGENCIES
<br />The county an jurisdiction numllcrs are prcifetennined and can be obtained by calling the State Board (916) 227-4303.
<br />assigned by the local agciicv; licm cycr, this nurnber must be numerical and cannot contain any alphabetical characters. If the local agency preforx
<br />the State Board to assign the facility number, please leave it blank.
<br />11' IS THE RESPONSMILITY OFTIII, LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br />INFORMATION, Tl IIS AllP I -ICATlON CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN'. THE LOCAL
<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 SHOUIJ)
<br />RETAIN THE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS. THE PINK COPY SHOULD BE
<br />RETAINED 13Y I IIF TANK OWNER.
<br />3.93
<br />STATE OF CALIFORNIA
<br />STATE, WATER RESOURCES CONTROL BOARD
<br />C/o S.W.F-E.P&
<br />DATA PROCESSING CENTER
<br />P.O. BOX 527
<br />PARAMOUNT, CA 90723
<br />FORD12DRI
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