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INSTRUCTIONS FOR COMPLETING FORM "A"
<br /> GENERAL INSTRUCTIONS:
<br /> SEICTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25285,25287,AND 2.5289 OF C11APTER
<br /> 6.7,DIVISION 20,CALIFOR-NIA HEALTH AND SAFETY CODE RE-QUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES orally FACILITY/SITEINFORMATION CHANGES.
<br /> 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the numberof 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 infortnation.
<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 2711(a)(8),CCRJ.
<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),CCRI.
<br /> TOP OF FORM:"MARK ONLY ONE ITEM""
<br /> Mark an(X)in the Ix)x next to the nern that best describes the reason the form is being completed.
<br /> L FACILITY/Srl'E 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 ACCrPTABLF.
<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 all Indian reservation or other Indian trust lands,check the box marked"YES".
<br /> 6. indicate the NUMBER of TANKS at this SITE.
<br /> T Record the E.P.A.11)#or write"NONE-in the space provided.
<br /> 11, PROPERTY 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 PROPERTY OWNERSHIPTYPI-,box.
<br /> IILTANK OWNER INFORMATION&ADDRESS(MUST BECOMPLL11D)
<br /> Complete all items in this section.Unless all items are the same as SECTION 1;If the same,write"SAME AS S1711."across this section. Be sure
<br /> to check TANK OWNERS TYPL box.
<br /> IV.BOARD OFEQUALIZATION 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 E(plaliZaliorl(1101:)UST storage fee account number which is required before your permit apply anon can be processed.
<br /> Re.gktrWiOl)with the 1101.o Will,orlswe that YOU will rCOCiVC a quarterly storage fee return in reponing the SWX)6(6nidls)per I�allcll fee duc on the
<br /> number uf gallons pla,:ccl in youl U'S 11's. `Tyre BOE will code Persons exempt from paying the storage feesk)I W,J 110 be sew. If vou ecu
<br /> ot
<br /> have an account nornber with the BOE or if you have any questions regarding tile fee or exemptions,pleise call the BOF at 916-322-96(i9 or Write
<br /> to the 13OL at the C01)wirlg address Board of Equalization,Fuel Taxci Division,P.O.Box 942879,Saorarrionlo,CA 942 794)001
<br /> V. PIAROLFUM UST FINANCIAL RliSPONSIBIIATY(MUST BE COMPLETED FOR PE IROI-13L',%l USTs ONLY,St'll'SE'C'l IONS 2i"11 (a)(S)
<br /> OFTITLE 23,CIIAVI L"R 16,CALIFORNIA CODE,OF REGULATIONS.)
<br /> Identify the nicthod(s)usod by tileowner and/or operator,in meeting the Federal and State firmicialwsponsibility FQ1jUiR!1MA'llS,U-STS OWi)Cd ky
<br /> any Federal or State agency as well as non-petroleurn USTs tire exempt from this requirement,
<br /> VI.LEGAL NO111FICATION AND BILLLNG ADDRESS
<br /> Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NO11FICATIONS,
<br /> TANK OWN'iR OR AUTHORIZED RF-'PRI..,SLNTATIVE NIUSTSI.GN AND DATETHE FOR,NI AS INDICA I'FD. IISFE Y4,11ONS 2711
<br /> (a)(13)OFT]II-E,23 CIIAIYI,Iqz 16,CALIFORNIA CODE OF RE.GULA'II0.NS.I
<br /> INS'IRUCTION FOR THE LOCAL AGENCII.iS
<br /> The county at)jurisdiction numbers are predetermined and call be obtained by calling the State,Board(9 T6)227-4303. Jhc facility number may be
<br /> assigned by the local agcncy;however,this number must be numerical and cannot contain any alphabetical characters. If the,local agency I)rcfLrs
<br /> 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 APIIIJCATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT `HA.LD IN. THE LOCAL
<br /> AGENCY IS RESPONSMLE FOR THE COMPLED-ION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR
<br /> FORWARDING ONE,FORM"A`AND ASSOCIATED FORM"B"(s)TO THF.FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN T1111 ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RETAINED BYTHF'.TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C110 S.W.E.E.P.&
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> FOR012OR1
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