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<br /> INSTRUSONS FOR COMPLETING FMAI "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,15287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTII AND SAI^"ET'Y 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 FACILITYI$1TE'INFORMATION.CHANGES.
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facilby/Site,regardless of the number of tanks located at the site, ,Sl
<br /> 3. This form should be cotnpleted by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR: .
<br />;Mp 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 agency as part of the application showing the location:of the USTs with respect to
<br /> buildings and landmarks[Section 27.11 (a)(8),CCRI.
<br /> 7. Tank owner mint 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)(I1),CCRI:
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Marlc,'aiM)in the box next to the item that best describes the reason the form is being completed.
<br /> L FACIIITYISITE 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 arid.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 ONVNERSHIP(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 TALKS at this SI'Z'E.
<br /> 7. Record the E.P.A.ID#or write"NONE"in the space provided.
<br /> U. PROPERTY OWNER INFORMATION&ADDRESS(MUST 111:COMPLETED)' '
<br /> Complete all items in this section,unless all iteans are the same as SECIION 1;If the same,wrile"SAME AS SITE"across this4ection. Be sure
<br /> to check PROPERTY OWNERSHIP TYPIi box.
<br /> IIT.TANK OWNER INI-OR MAlION&ADDRESS(MUST BE,COMPLF.,TED)
<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 TANK OWNERS TYPE box. {�
<br /> IV,BOARD OF L•:QUAI.1'LATION UST STORAGE FEE:ACCOUNT NUMBER(MUST BE CONTPLET'ED.SEE ARTICLE'5,CIIAP`I'EiR 6.75,
<br /> DIVISION 20,CALIFORNIA Ill ALT'11 ANDSAFETYCODE.)
<br /> Enter your Board of Equalization(BOT.)UST storage fee account number which is required beforeyour permit applicaflon can lie.processed.
<br /> Re,;stratiop,ti ith the 13013 will CtiSnrC that you will receive a quarterly storage fee rtAum in,reponing the,$0.W6(Oruilk)per gAon fee aur;'qn the
<br /> ntmnbcr of gallons placed in your US'ls. The BCH'.will code persons exempt.from paying the storage fee so return,will not lar,sent. If you do,not
<br /> have in account nuumbct with the BOE ur if you have.any questions regarding the fcc or exemptions,please call the BOl at 916-3'22-9669 or write
<br /> to the 1301-'a the following addr.,a Beard of Equalizatiun,Fuel.Taxes Division,P.O.Box 9.12479.Sacramento,CA 94279-0001,
<br /> V. !IFSPONSIBIZ_IT'Y(MUST"13L COMPLETED FOR PE IROLEUM UST,ONLY,Si:E3`,13C:"1'1(3\S 2711(a)(S)
<br /> OF TIT'1_E 23,CHAPTER 16,CALIFORNIA CODE OF RIiGULATION'S.}
<br /> Identify the ntcthod(s)used by the owner and/or operator,in meeting the Federal and State financial responsibility requuemctats.USTs owiwd by
<br /> any Federal or State agency as well as non-petroleum LISTS are exempt from,this requirement
<br /> VI.LEGAL NO"III ICATION AND BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIRCATIO.NS
<br /> TANK OWNER OP.AUT UORIZEi?I*iP1I T{,S ,tiT'A I1V F.M1;ST SIGN AND DATE THE FORM AS Ia\:L3ICAT'1;D. {SI.I: l.;<:FI{5ti5 2711
<br /> (a)(13)OF IT'1'LE 23 CHAPTER 16,CALIFORNIA CODE 0 REGULATIONS)
<br /> INSTRUCIION FOR THE LOCAL AGENCIES
<br /> The county an jurisdiction numbers are predetennhted and can be obtained by calling the State Board(916).127-4303. The facility number may he
<br /> assigne_d by the local agency;however,this number must be numerical and cannot contain any alphabetical char'actcis: If the local agency prefers
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS THE RESPONSIBILITY OF TIIE LOCAL AGENCY THAT INSPECTS THE FACILI'T`Y TO VERIFY THE ACCURACY OF mr-,
<br /> INFORMATION. T'fHS APPI.ICA'IION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER ISNOT FILLED IN. THE'I.00AL
<br /> AG1:3NCY .1S 121?SI1ONSIBI..E FOR TIIE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN TI 11:ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.TH.E,PINK COPY SHOULD BE
<br /> RLTAINL'1)BY TI IE TANK OW'N'ER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> CIO S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527 _;{
<br /> PARAMOUNT,CA 90723 r
<br /> 3:'93 FOR012ORI
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