|
J
<br />INSTRUCTIONS FOR COMPLETING FORM "A"
<br />GENERAL INSTRUCTIONS:
<br />SECTION 2711 OF TITLE 23, CHAPTER 16, CAI IFG°RNI A CGDE C7F REGULATIONS AND SECTIONS 2±286, 25287, AND 25289 OF CHAPTER
<br />6.7, DIVISION 20, CALIFORNIA HEALTH AND SAFETY CGDE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br />1. One FORM "A" shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORNIATION CHANCES.
<br />2, SUBMITONLY ONE (1) FORM "A" for a Facildyl5ite, 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 haat point wri6.V inpruliem, yob arc a'ki 3 copies,
<br />6. Tank owner roust submit a facility plot plan to the local agency as part of the applicationshowing the location cf tlie'F>st v'ith rtspent to
<br />buildings and landmarks [Section 2711, (a)(;),,.CCRJ.
<br />7. Tank owner roust submit documentation .4howing dampliancc with °state financial responsibility reg4iremehtt to the l6cal agency as #art bf,the
<br />application for petroleum USTs [Section 2711 (a)(I 1), CCR).
<br />T01 4 FORk: "M RK t)IkY ONE ITEM" c
<br />Mark an (X) in the box next to the item that best describes the reason the form is being completed.
<br />I. FACILITYISITE INFORMATION & ADDRESS (MUST BE COMPLETED)
<br />I , Record name and address (physical location) of the underground tank(s).
<br />NOTE: Address NIUJIST have a valid physical location including city, state, and zip cock,
<br />P.O, BOX NUMBERS ARE NOT ACCEPTABLE.
<br />Include nearest cross street and name of the operator
<br />2, Phone number roust ha -,e an arca code. If the night number is the same, write "SAME" in proper location.
<br />1 Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.).
<br />Check the approptsaate box for TYPE OF BU INE S. a
<br />5, If Facility/Site is located within an Indian reservation or lather Indian trust lands, check the box marked "YES".
<br />6,. l icilte"the NUMBER of TAINMKSat this SITE: a -
<br />7. Recon{ the ,P,A, Iia 4 or write 'N€3N' in the space provided.
<br />11, PROPERTY OWNER INFORMATION & ADDRESS (MUST BE COMPLETED)
<br />Complete all items in this section, unless all items arc the same as SECTION l; If the same, write "SAME AS SITE" across this section, Be sure, l
<br />to check PROPERTY OWNERSHIP TYPE box, . e - %
<br />III. TANK GINNER INFORMATION fir, ADDRESS (MUST 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" across bis station. 'Be sure
<br />to check TANK OIVNERS TYPE box,
<br />IV, BOARD OF EQUALIZATION UST" STORAGE FEE ACCOUNT NUMBER (MUST BE COMPLETED. SEE ARTICLE 5, CHAPTER 6,75,
<br />DIVISION 20, CALIFORNIA HEALTH AND SAFETY CODE.)
<br />Enter your Board of Equalization (BOE) USTstorage fee account number which is required before your permit application can be processed.
<br />Registration with the BOE will ensure thaw you will'receive a quarterly storage fee return ipreporting the per,gallitn fee due 9h the number of
<br />gallons placed in your USTs, The BBE vain code° persons exempt from paXlWg the sti!iaagc 156esoreturxis (vili riot be 'sent, k you cio not have aro ¢
<br />account number with the BOE or if you have any questions regarding* the fee or exemptions, please: call the BOE at 916-322-9669 or write to the
<br />BOB at the; following address Bored of Equalization, Fuel `Faxes Invision, RO, Box 942879, Sacramento, C&94279 -OWI,
<br />V, PETROLEUM UST.FINANCIAL RESPONSII?IL,ITY (MUST BE COMPLETED FOR PETROLEUM LSTs ONLY, SEF SECTIONS 2711 (4)(11)
<br />OF TITLE 23, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS,)a
<br />Identify the method(s) used by the ownerand/or operator, in meeting the Federal and State financial responsiIbility requirements. USTs owned by
<br />any Federal or State agency as well as non -petroleum USTs are exempt from this requiremeriL
<br />VI, LEGAL NOTIFICATION AND 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 DATE 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 calling the State Board (916) 227-4383, The facility number may
<br />be assigned by the local agency: however, this number must be numericaland 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 THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY 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 THE "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 />d
<br />
|