|
9 0
<br />INSTRUCTIONS FOR COMPLETING FORM "A"
<br />GENERAL INSTRUCTIONS:
<br />SI CTION 2711 OF "TITLE 23, CIIAPT'I R 16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286, 25287, AND 25289 OF CHAPTER
<br />6.7, DIVISION 20, CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS -KO APPLY FOR AN UST OPERATING PERMIT.
<br />1. One FORM "A" shall be completed for all NEW PERMIT CHANGES or any FACILrN/SITE 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 UNDM- GROUND 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 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 as part of the
<br />application for petroleum USTs [Section 2711 (a)() 1), CCRI.
<br />TOP OF FOIUM: "MARK ONLY ONE .ITEM"
<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 name and address (physical location) of the underground tank(s).
<br />NO"TE: Address MUST have a valid physical location including city„state, and zip code.
<br />t
<br />P.O.13OX NUMBERS ARE N0. ACCI l`rABLE.
<br />Include nearest cross street and name of the operator. _,,,
<br />I Is2itfi
<br />2. Phone number must have act area code. If the night number is the same, write "SAME” in proper location.
<br />3. Check the appropriate box for TYPE OF BUSLt\1;SS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.).
<br />er, t 4 j:'-= } -WA14
<br />4. Check the appropriate box for TYPE OF BUSINESS.
<br />5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES".
<br />- ].
<br />6. Indicate the NUMBER of TANKS at this SITE.
<br />, dx>t
<br />7. Record the E.P.A. ID #[ or write "NONE" in the space provided.
<br />I.I. PROPERTY OV, NI'R INFORMATION tR, ADDRESS (MUST 13L COMPI.ETI D)
<br />Complete all items in this section, unless all items are the same as SECTION 1; If the same, write "SAME.. AS SITE"
<br />across this se.rr tion. Be sure.. MALI
<br />to check PROPERTY OW NF.RS111I' TYPE box.
<br />=
<br />III. TANK OWNER INFORMATION & ADDRi SS (h1USt" BE COMPLETED)
<br />Complete all items in this section, unless all 'items are the same as SECTION 1; If the same, write "SAME AS SITE"
<br />across this section. Be sure
<br />to check TANK OWNERS TYI'I box.
<br />IV. BOARD OF E.QUAI_IZAT ION LST STORACtI, FEE" ACCOUNT NU.MBI-iR (MUST BE COMPLE` IED. SEE ARTICLE 5, CIIAPTL�R6.75,
<br />DIVISION 20, CALIFOR.NTA HEALTH ARID SAFF;TY CODE.)
<br />Enter your hoard of E,lual iratiwi (130E) UST storage fee account nurnber which is required before your permit application can he prore.tsed.
<br />Rq'ist-ation willi Inc 1301, will nn:u:o that you will receive a quarterly storage fee retum in reporting the S0.0)6 (6mil:. her }Tallon fee due, ort the
<br />number of gallons placed tr: yoar US I's. 'Ihe BOL will code persons exempt from paying the Storage fee so rct.etrr,s wiilnot be scia. If you do not
<br />have, an account nuinbe'r with the 130E or if you have any questions regarding the fee or exemptions, please call the 1 Okl ai 9116 322 9669 or write
<br />to the BOE at the following addicss Bo..rd of Llualization, Fuel Taxes Division, P.O. Box 942879, Saciamcnio, Cil 942 9 {)Ut11.
<br />V. I1E'I1t0I.l:U.M US f FINANCIAL RFSPONSIBILITY (MUST BE CO-10PLET'ED FOR I11�1 ROLEUN1 LI -STs ONLY, SEI. SECTIONS 2711 (a)(S)
<br />Ol 1T'IT-l' 23, CIIAP ER 16, CALIFORNIA CODI.,. OF REGULATIONS.)
<br />Identify t[tc trt.thud(s) used by the owner and/or operator, in meeting the Federal and State Financial responsibility reyt u..it,t.nt:. USTs a nod by
<br />ally Fedcr:a or Statc agency as well as non -petroleum USTs are exempt from this requirement.
<br />VI. LEGAL, NOTIFICATION AND I3TLL,I\G ADDRESS
<br />Check ONE BOX fur the address that will be used for IJOTIl LEGAL AND BIL LING NOT'IF[CA TIONS.
<br />TANK OWNER OR AUTHORIZED REPRF:SENT'ATIVE MUST SIGN AND DATETHE-FORM AS INDICATIi1,). [tete: SFC fJONS 2711
<br />(a)(13) OF T.ffLF 23 CIIAPFER 16, CALIFORNIA CODE OF REGULATIONS.]
<br />INSTRUCTION FOR TILE LOCAL AGT'NClES
<br />The county an jurisdiction numbers are predetermined and can be obtained by calling the State; Board (916) 227-4303. The lacwl,,. number may he
<br />assigned by the local agcncy; 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 Till: R[-'SPO\SIBILI TY OF TITS, LOCAL AGENCY THAT INSPECTS THE FACII:ITY `f'O VERIFY THE ACCURACY OF THE
<br />INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLI,-11 I.N. THE LOCAL
<br />AGI NCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFOR.44A11ON BOX AND FOR
<br />FORWARDING O F'. FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD'
<br />RI:'TAI.N TIll.; ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS. THE PINK COPY SHOULD BE
<br />Rhl'AINED BY TI IE TANK OWNER.
<br />STATE OF CALIFORNIA
<br />STATE WATER RESOURCES CONTROL BOARD
<br />C/O S. W.E.E.P.S.
<br />DATA PROCESSING CENTER
<br />P.O. BOX 527
<br />PARAMOUNT, CA 90723,
<br />3.93_
<br />•:t��z� :�,k ,�. �: �ti: �s �."rtlz t ci.,
<br />FOi10t20ii
<br />
|