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<br />INSTRUCTIONS FOR COMPLETING FORM "A"
<br />GENERAL INSTRUCTIONS:
<br />SECTION 27,11 OF TITLE 23, CHAPTER Ifs, CALIFORNIA CODE OF REGULATIONS AND SECTIONS -'5286,25287, AND 25289 OF CHAPTER
<br />6.7, DIVISION 20, CALIFORNIA HEALTH AND SAI'TTY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT,
<br />1. One FORM "A" shall be completed for all NEW PERMIT CHANGES or anyFACILITY/SITE INFORMATION CHANGES,
<br />2, St BMIT ONLY ONE (I) FORM "A" for a FacilnytSite, 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 hard point writing instrument, you ;are making 3 collies.
<br />6. Tarek owner must submit a facility plot plan to the local agency as part of the application showing the location of the LSTs with respect to
<br />buildings and landmarks [Section 2711 (a)(8), CCR].
<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 (a)(I 1), CCRJ.
<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 beim completed.
<br />L FACILITY/SITE INFORMATION & ADDRESS (MUST BE COMPLETED)
<br />I . Record corns and address (physical Iocationt) of the underground tank(s),
<br />NOTE: Address MUST have a valid physical location including city, state, and drip 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 bort for TYKE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.).
<br />E. Check the appropriate box. for TYPE OF BUSINESS,
<br />S. If Facility/Site is located within an Indiana reser-nation or other Indian trust lands, check€he box marked "YES".
<br />6. Indic=ate the NUMBER of TANKS at this SITE.
<br />7, Record the E.P,A. ID ff or write "NONE" in the spm provided.
<br />Il. PROPERTY OWNER INFORMATION & ADDRESS (MUST BE COMPLETED)
<br />Complete 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 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 LIST 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 />Registration 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 [,LSTs. 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 von have any questions regarding the fee or exemptions, please call the BOE at 416-322-9669 or write to the
<br />BOE at the following address Board of Equalization, Friel `Faxes Division, P.O. Box 942879, Sacramento, CA 94279-0001,
<br />V. PETROLEUM UST FIN.ANC:IAL, RESPONSIBILITY (MUST BE COMPLETED FOR PETROLEUM USTs ONLY, SEI: SECTIONS 2711 (a)(I1)
<br />OF TITLE 23, CHAPTER 16, CALIFORNIA COLE OF REGULATIONS.)
<br />Identify the method(s) used by the owner andlcnr operator, in meeting the Federal and State financial responsibility requirements. USTs owned by
<br />any Federal or Starr agency as well as non-petrolearn LISTS are exempt from 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 NOTIFICATIONS.
<br />TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. (SEE SECTIONS 2711
<br />(a)([ 3) 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 TI IE 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,
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