|
INSTRUCTIONS FOR .L.3 .. aF "A"
<br /> GENERAL IN ST RUC T IONS:
<br /> t
<br /> SECTION 2711 OF TITL E 23,#;t APTL.R 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS"_5286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,C YL,IFORNI A HEALTH AND SANE"f4 i"ODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT,
<br /> I, One FORM"A`°shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES,
<br /> 2. SUBMIT ONLY ONE(I)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 toff requested snfortnation,
<br /> 5. Use a hard paint writing instrument,you are snaking 3 copies.-
<br /> 6. Tank owner must submit a facility plot plana 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 must subtrat 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 1),CCR).
<br /> TOP OF FORMi "MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the hero that best describes the reason the form is being completed.
<br /> I. FACILITY/SINFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> t. Record name and address(physical location)of the underground tank(s).
<br /> NO"T"E: Address MUST"have a valid physical location including city,state,and zip code.
<br /> P.O.BOX NUMBERS ARE NOT ACCEPTABLE.
<br /> Include neamst cross street and name of the operator,
<br /> 2. Phony;number roust have an area code. If th6 sight number is the came,write"SAME"in properlocation.
<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";"DONE"in the space provided.
<br /> 1I. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items it,,this section,unless all items are the same as SECTION I;If the same,write"SAFE AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSIIIF TYPE box.
<br /> III.TANK OWNER INFORMATION N&ADDR `3S(MUST BE COMPLETED)
<br /> Completer all items in this section,unless all items are the same as SECTION I;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check TANK OWNERS TYPE box,
<br /> TV.BOARD OF EQUALIZATION UST T`S T'ORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED,SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFETYCODE.)
<br /> Enter your Board of Equalization(BOE)UST storage fel,:account number which is required before your permit application can be processed.
<br /> Registrations with the BOE will ensure that you will receive a quarterly storage fee return in reporting 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 fee so returns will not be sent. If you do not have an
<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 Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0001.
<br /> V. PETROLEUM US r s INANC'IAL RESP d`NS13ILITY'(MUST BE COMPLETED FOR P17TROLEUM USTs ONLY,SEE SECTIONS 2711 (a)(I 1)
<br /> OF TITLE 23,CHAP"fER 16,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the me hods)used by the owner and/or operator,in meeting the Federal and State Financial responsibility requirements.USTs owned by
<br /> any Federal or State agency as well as nein-petroleurn USTs are exempt from this requirement,
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Check ONE BOK 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)(I3)OF"TITLE 23 CHAPTER 16,CALIFORNIA CODE,OF REGULATION?.]
<br /> INSTRUCTION FOR THE LOCAL,AGENCIES
<br /> The county and jurisdiction number%are predetermined and can be obtained by calling the State Board(916)227-4301 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 tho facility number,please leave:it blank.
<br /> IT THE R alaONFIB_L, _011-71E, t itC,L-; CEN -IAT rNS E TS THE FACILITY TO VERIFY THE ACC.I.3 ACY OF THE
<br /> INFORMATION, THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS N&FILLED IN,' THELOCAL
<br /> AGENCY" IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY CJSF ONLY" INFORMATION BOX, THE LOCAL
<br /> AGENCY SHOULD RETAIN THF ORIGINAL AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK,
<br /> OWNER.
<br /> 6/95 `
<br />
|