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INSTRUCTIONS FOR. COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> ECTION 2711 OF TITLE 23•,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> -' :7,-DIVISION•20,CALIFORNIA HEALTH AND SAFETY CODE 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 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 /> t 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 hard point writing instrument,you are making 3 copies,
<br /> 6. Tank�owner must submit a facility plot plan to the local agencYAs part of the application showing the location of the USTs with respect to
<br /> buildings and landmarks[Section 2711 (a)(8),CCR).. 1
<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 ia)(11),CCR].
<br /> TOP OF F07, :''MARK ONLY ONE ITEM" F
<br /> Mark a � box next to the item that best describes the reason the forin is b6ggi c.o, pleted. ,
<br /> I. FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<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 6WNER!HJP(ex.GORPORAT[ON,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPE OF BUSINESS.
<br /> 5, If Facility/Site is located within an Indian reservatioA or other Indtan trust lands,'cheek 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 /> II. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all itergs are the same as SECTION l-,If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> III.TANK OWNER INFORMATION&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 this section. Be sure
<br /> to check TANK OWNERS 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)UST storage fee account number which is required before your permit application can be processed.
<br /> RegisiwO"With the BOE will ensure that:you will receive a quarterly storage fee rets"m in reporting the per gallon fee due on the,humbe'r of
<br /> gallons placed in your USTs. The BOE wi$pNp o{I p t Wt from paying tllq stprgg 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 /> BOE at the following address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0001.
<br /> V. PETROLEUM LIST FINANCIAL RESPONSIBILITY,(MUST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711(a)(I 1)
<br /> OF TITLE 23,CHAPTER If,CALIFORNIA CODE OF REGULATIONS.)
<br /> Identify the method(s)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 non-petroleum USTs are exempt from this requirement.
<br /> VT.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)227-4303. 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 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 BOE ACCOUNT NUMBER IS NOT FILLED IN, THE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION•OF THE "LOCAL.AGENCY IUSE'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 /> 6/95
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