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INSTRI,TCTIONS FOR COMPLETING"A"
<br />GENERAiL ISI a° RIS TIONS;
<br />SECTION 2711 OF TITLE 23CHAPTER .16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 252&6, 25287, AND 25289 OF CHAPTER
<br />6.7, DIVISION 20, CALIFORNIA HEALTH AND SAF17TY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br />1, One FORM;'A` shat; 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 fors 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 plata to the local agency as part of the application showing Use location of the USTs with respect to
<br />buildings and landmarks [Section 2711 (a)(8), CCR],
<br />7., Tank owners€gust 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)(i 1), CCR].
<br />TOP OF FORM: "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 />1, FACIL.ITYISITE INFORMATION & ADDRESS (MUST BE COMPLETED)
<br />-i, Rec6rd 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 crass street and mute of the operator.
<br />2. Phone number must have an area code, if the night number is the same, writka "SAME" its 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 reservations or other Indian trust ]amts, check the box marked "YES".
<br />6. Indicate the NUMBER of TANKS at this SITE.
<br />7. Record the E,P,A. IO # or write "NONE" in the space provided.
<br />11, PROPERTY OWNER INFORMATION & ADDRESS (MUST BE COMPLETED)
<br />Complete ail items in this section unless all items are tae same as SECTION I; 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 ;his section, unless all _terns :arc 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 RE COMPLETED. SEE ARTICLE 5, CHAPTER 5.75,
<br />DIVISION 20, CALIFORNIA HEALTH AND SAF`ET " CODE,)
<br />Enter your Board of Equalization (BOE -1 UST storage fee account number which is required before your permit application can be processed.
<br />Registration wida the BOE will ea tut, that you will , receive a quarterly storage fee return in reporting the per gallon fete due on the number of
<br />g lens placed in your USTs. The BOE will cods persons exempt from paying the storage fee so returns will not be sent. if you -do not have an
<br />account number .with the ETOL; or if you have any que<ttaons regerdizag the fee or exetraptions, please call the BOB at 916-322-9669 or write to the
<br />BOB at the following address Board, cif Equalization. Fuel Taxes Division, P.O. Box 942579, Sacramento, CA 94279-0001.
<br />V. PETROLEUM M UST FINANCIAL RF TPONSIPIL.ITY (MUST BE COMPLETED FOR PETROLEUM USTs ONLY, SEE SECTIONS 2711 (a)('I 1)
<br />OF TITLE 2.3, CHAPTER 16, CA II'(3S`NIA CODE OF REGULATIONS,)
<br />Identify the method(s) used by the own r and/or operator, in meeting the Federal and State financial responsibility requirements. LSTs owned by
<br />any Federal or State agency as well as non-petr;leurn USTs are exempt from this requirement.
<br />VI. LEGAL NOTIFICATION AND 13ILLING ADDRESS
<br />Check ONE 13OX for the address that will be used for BOTH LECxAL AND FALLING NOTIFICATIONS.
<br />TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN ANIS DATE THE FORM AS INDICATED, (SEE SECTIONS 2711
<br />(a)(13) OF TITL E 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 inust be numerical and cannot contain any alphabetical characters. If the local agency
<br />prefers the State- Board to ,, sign t w facility number, please leave it blank.
<br />IT IS THE fi SE1 , .. €° I' .., � t - � FACILITY TO VERIFY Tile ACWCIJRACY OF THE
<br />�,�._.. ne._,. ..,._.�. z HE
<br />INFORM ATTON. THIS APPLICATION i ANNOT BE PROCESSED IF THE BOB ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL
<br />AGEiNC Y_ IS,REES s .t,:,SIB E, FOR 111 tt 1MPI.ETTION OF THT, "LOCAL AGENCY USE ONLY" INFORMATION BOX, THE LOCAL
<br />AGENCY Sl -O 'LD RE' AINv TH1,'0RlG1,N,AL AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY THE TANK
<br />OWNER,
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<br />0 IN
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