|
INSTRUCTIONS FOR COMPLETING FORM "At'
<br />GENERAL INSTRUCTIONS:
<br />SECTION 2711 OF TITLE 23, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286, 25287, AND 25289 OF CHAPTER
<br />DIVISION 20, CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT.
<br />I. One FORT "A" shall be completed for all NEW PERMIT 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 form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANI" INSPECTOR,
<br />4. Please tyke 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 1=d agency as part of the application showing the location of the USTs with respect to
<br />buildings and landmarks [Section 2711 (a)(g), CCR).
<br />7. Tank owner trust 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 hest describes the reason the form is being completed.
<br />I. FACILITY/SITE INFORMATION & ADDRESS (MUST ISECOMPLETED)
<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.OBOX NUMBERS BERS ARB NOT ACCEPTABLE.
<br />Include nearest cross street and name of the operator.
<br />2. Phone number must have an arca carie. 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. ITS # 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 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 (?BUST 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 Haat you will receive a quarterly storage fee return in reporting the per gallon fee due on tlae number of
<br />gallons placed in your USTs. The BOB will code persons exempt from paying the storage fee so returns will not be sent, if y do not have an
<br />account number with the BOB or if you have any questions regarding Elie fee or exemptions, please call the BOB at 916-322-9669 or write to the
<br />BOE at the following address Berard of Equalization, Fuel 'Taxes Division, P,O. Box 942879, Sacramento, CA 94279-0001,
<br />V, PETROLEUM UST FINANCIAL. RESPONSIBILITY (MUST BE COMPLETED FOR PETROLEUM USTs ONLY, SEE SECTIONS 2711 (a)(I1)
<br />OF TITLE 23, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS.)
<br />Identify the method(s) used by the owner and/or operator, in meeting the Federal and State financial responsibility requirements. USTs owned by
<br />any Federal or State agency as well as non -petroleum USTs are exempt from this requirement.
<br />VI, LEGAL :NOTIFICATION AND BILLING ADDRESS
<br />Cheek ONE BOX for the address that will be used for BOTH LEGAL ANIS BILLING NOTIFICATIONS.
<br />TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN ANIS DATE THE FORM AS'INDICATED. (SEE SECTIONS 2711
<br />(a)(I3) OF TITLE 23 CHAPTER 16, CALIFORNIA CGDE OF REGULATIONS.)
<br />INSTRUCTION FOR THE LOCAL AGENCIES
<br />The county and jurisdiction numbers are predetermined and can be obtained by calling the State Bo (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,a
<br />IT IS THE RESPONSIBILITi' 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 THE COMPLETION OF TIME "LOCAL. AGENCY USE ONLY" INFORMATION BOX. THE LOCAL
<br />AGENCY SHOULD RETAIN THE ORIGINAL. AND YELLOW COPIES. THE PINK COPY SHOULD BE RETAINED BY TIME TANK
<br />OWNER,
<br />fi.'�S
<br />
|