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INSTRUS 7i IPLETING AM "Alt
<br />01ON- C(M
<br />GENERAL INSTRUCTIONS:
<br />SECTION 2711 OF-1ITLE 23, CHAPTER l6,CALIFORNIA CODF OF REGULATIONS AND SECTIONS 2<-)86,25287,,XND, 25289 OF CHAPTER
<br />6 . 7, DIVISION 20, CALIFORNIAHEALTH AND SAFETY CODE REQUIRE OWNERS "_ ; APPLY FOR A',' :ST OPERA'1TN-GPER. IT.
<br />One FORA "A" -,hall be completed for all NEW PERMIT CHANGES or any FA,r'!: I'l-Y, S': Ir _,,1,4 TIO CHANGES,
<br />SUBMIT ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks;(, 1t,,d a, the site.
<br />This farm should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY L, NIA"RGROUND TANK INSPECTOR,
<br />Please type or print clearly all requested information.
<br />Use a hard point writing instrument, you are making 3 copies.
<br />Tank owner must submit a facility plot plan to the local agency as part of the application showing, the locat wn of the USTs with respect to
<br />buildings and landmarks [.Section 2711 (a)(8), CCR].
<br />Tank owner must submit documentation showing compliance with state financial resp,., -
<br />c :1 v,,,prcm,,,Pats to the local agency as part of the
<br />application for petroleum USTs [Section 2711 (a)(I 1), CCR].
<br />TOP OF FORM: "MARK ONLY ONE ITrM"
<br />Mark an (X) in the box next to the item that best describes the reason the form is being completed,
<br />FACILITY/SITE ]INFORMATION & ADDRESS (MUST BE CONIPLETED)
<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 code.
<br />P.O, BOX NUMBERS ARE NOT ACCEPTABLE.
<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 TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.),
<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 />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 />IL PROPi,1R,rY OWNER LtiFORNIAIION& ADDRESS (MUST Bi-, COMPLEIT',D)
<br />Complete all items in this section, unless all items are the same as SE,C'IION 1; If the same, write "SAME AS SITE" across this section. Be sure
<br />to check PROPERTY OWNFRSI TIPTYPE box.
<br />Ill. TANK OWNER INFORMATION & ADDRESS (NIUST 13E 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 this section. Be sure
<br />to check TANK OWNERS TYPEbox.
<br />IV, BOARD OFEQUAIJZATION UST STORAGEPEE. ACCOUNT NUMBER (MUST BE COMPLETED. SE -.E ARTICLE 5, CIIAP`lTR 635,
<br />DIVISION 20, CALIFORNIA IlliAL-I'll AND SAFE , I'Y CODE-)
<br />Enter your Board of Equalization (1101.,) UST storage; fee account number which is required before your pen r C:di be processed.
<br />Registration Nvnh 1110 B01H will'aisum that you will receive a quarterly storage fee return in reporling the 50.006 puf gallon fee due on the
<br />nunnbcr of fallonsnlaccd in vollf USTs. ThO 130E will code fx;rsons exempt from paying the storage fee so returns will no, be sent. If you do not
<br />have an account nunibcr woh the 130i.'ur if You have any questions regarding die fee or exemptions, please call the WE at 916-:32"2.9669 or write
<br />to the 130t, at 1,13 follwAin I I
<br />-g fidldTo�s Board of Equalization Fucl Taxes Division, P.O. Box 94.2879, Sacramento, CA 9 1279- tI(i1.
<br />V. PE'I'IZOI,l�U44US'I'I,'INA-NCIAI,itllSIICJ.\,S]I3T[,I'fy(MUS-1-13FCOMl)I
<br />ETED FOR PEIROLUU.M USTs ONLY, SELSE.C'l IONS 2711 (a)(8)
<br />OF TITLE 23, CHAPTER 16, CALIFORNIA CODE OF REIGULATIONS.)
<br />IdentifV the rnedu>d(s) used by thc, owner and/or operator, in Knecting the Federal and Slaw financial responsibility rCQuhancxas. USTS owrlr:d by
<br />any Federal or State agency as well as non-petrolcurn USTs are exempt frorn this requirement,
<br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS
<br />Check ONE BOX.for the address that will be used for BOTH LEGAL AND BILLING, NOIJFICATIONS.
<br />TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATIfTIll: FOR.,`0 AS INDICATED. JSIAi SECI JONS 2711
<br />(a)(13) OF `T'IT'LE 23 CI IAPTER 16, CALIFORNIA CODE OF REGULATIONS.]
<br />INSTRUCTION FOR TIFF LOCAL AGh.NCIl,.S
<br />The county :m I nuufl.wrs are predetermined and can be obtained by calling the State Board (916) 227-4303. The facility number may be
<br />assigned by t .y; however, this number must be numerical and cannot "Int -am any alphabetical characters. If the local agency prefers
<br />the State Board w—, uio facility number, please leave it blank.
<br />IT IS THE' RESPON; , Y OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY, OF THE
<br />LNFORMATION ""TION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL
<br />AGENCY IS Rz JTHE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br />FORWARDING \ND ASSOCIATED FORM "B"(s)TO THE FOLLOWING ADDRESS, THE. LOCAL AGENCY SHOULD
<br />RETAIN THE. 0,.i,-�', FORWARD THE YELLOW COPIES TOTHE FOLLOWING, ADDRESS. THE PINK COPY SHOULD BE
<br />R11,."I'AINED BY'l HA.,TANK OWNER. . I
<br />STATF'OFCALIFORNIA
<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 />PARANIOUNT, CA 90723
<br />31r93 FOR012OR1
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