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INSTRUCTIONS FOR COMPLETING FORM "All
<br /> GENgAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER .
<br /> 6.7;DIVISION 20,CALIFORNIA 1lEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT T 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 /> 3. This fort 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 submita facility plot plan 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),CCRI.
<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)(11),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 /> I. FACILITY/SITE TNFORMA'11ON&ADDRI?SS'(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 NOTACCEPTABLE.
<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 /> H. PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this scctioa,unless all items are the same as SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP TYPE box.
<br /> M.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> Complete all items in this section,unless all items are the same as SECTION l;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check TANK OWNL'RS"TYPE box.
<br /> IV,BOARD OF EQUAI._I.ZAT fON UST`STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEB ARTICLE 5,CIIAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH AND SAFE"i'Y CODE.)
<br /> Enter your Board of Equal ization(110E)UST storage fee account number which is required before your permit application can be processed.
<br /> Registration with the BOE will erasure that,you will.receive a quarterly storage fee return in reporting the S0.0)6(6mills)per gallon fee due on the
<br /> number of gallons placed in your LIS T's. The BOE will code persons exempt from paying the storage fee so returns will not be sent. If you do not
<br /> have an account mimbcr with the BOE or if you have any questions regarding the fee or exemptions,please call the BOE at 916-322-9669 or writc
<br /> to thel.3011'at the folio"ung address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 9.1279-0001.
<br /> V. PE"IROL.EUM LST FINANCIAL.RESPONSIBILITY(MUST BE COMPLETED FOR PET ROLEUII LSTs ONLY,SEE SI'CTIONS 2711 (a)(8)
<br /> OF IIII..E 23,Cl IAPTER 16,CALIFOILN IA CODE OF REGULATIONS.)
<br /> Identify the Intahexl(s)used by the owner andlor operator,in mecting the Federal and,State financial responsibility tequnn .nicnl.s,USTs wined by
<br /> any Fedccdl or State agcrwy as well as I1on-[>etroleuin DST's are exempt from this requtrernent.
<br /> VI.LEGAL NOTIFICATION AND BILLING ADDRESS
<br /> Chcck ONE BOX for the address that will be used for BOTH L,11GAL AND BILLING'NOTIFICATIONS,
<br /> TANK OWNER OR AUTHORIZED REPRIFSENTATIVE MUST SIGN AND DA'TL Till;FORM AS INDICATED. [SI F.SECTIONS 2711
<br /> (a)(13')OF TITLE 23 CIIAI'ITiR 16,CALIFORNIA CODE OF REGULATJONS.]
<br /> INSIRUC"17ION FOR TILE 1.0CAL AGENCIES
<br /> The county an jurisdiction nutmbers are predetermined and can be obtained by calling the State Board(916)227-4303. The.(aciii?y number may be
<br /> assigned by the local agency;however,this number most be numerical and cannot contain any alphabetical-characters. If the local agency prefers
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS TI IE 'RESPONSIBILITY OF THE LOCAL AGENCY T14AT INSPECTS THE FAC:IL.ITY`I'O VEI2IFY THE ACCURACY OF"TIIE
<br /> INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THELOCAL
<br /> AGENCY IS RESPONSIBLE FOR TIIE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> I.ORWARDI.N(:I ONIF FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. TIIE LOCAL AGENCY SHOULD
<br /> RETAIN THE,ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BY"I'IIF. TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C/O S.W.E.E.P.S.
<br /> — DATA PROCESSING CENTER p< --
<br /> J - P.O.BOX 527 'a'
<br /> PARAIVIOUM F,CA 90723
<br /> 3193 _
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