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<br />Ex's~ ,, _e .,,"ri. . NSy �- C OINIP E'. .,iNG 11,0[ ,N " I A I I
<br />GENE LNSTz UC'TIC NS:
<br />lfi. CALli ORNIA COFX OF REG LAT ON'S AND tiE C IONS 2S,286,25287, AND 3528=9 OF CHAPTER
<br />6,77 1,s y ,S:, ._ ��, �i`: ,.. 'lr1 HEALTH ANSAFETY C C)I0I. i() APPLY a Fi:)ii AN USTOPERATING RATIN(; Pi 12 vn1"P.
<br />1. O t ,RM " ::°r '1 b-V;mpleted for all NEW PERN41T CHANGES or any ,l"i` ISI"I'4:i tai tlf �1'�Tii.}i {'HA�t:fF �.
<br />2, kl . ,t NE (I'3 FORM "A" for a Facilit},`situ, r -Wordless of the; n€ mbcs ,af: tanks loc,-,acd at lh,, siie;.
<br />3. Tf.,� _. �. _ . �..l:,,od by either the PER;IIIT APPLICANT or (he LOCAL. AGENCi L;;\'I.)ERGROI,NS?'TANK INSPF:CT'OR,
<br />3B omested information.
<br />you are making :$ copies
<br />r. ;ac =1ity plot pian to the locaai a(*en �«= a4 part of°the appTiva€ion sPzr€u'in the.o--t?nn of ;he L STs with respect to
<br />ba ,s: inJ l:andnaau'� (Section 2711 (a)(8"1. CCR;.
<br />7. Tanis ow€ter must s€:bnait documentation showing compliance; :vith state f€naancial , r--ponsibility retluir-erncnts t a the local agency as part of the
<br />application for petroleum C, S`i's [Section 2-711 (a)01). CCRIj
<br />TOP OF FORM: "MARK ONLY ONE ITEM"
<br />Mark an (X) in the box nest to the item that best describes the t , qrn the form is hei:'., completed.
<br />FACILITY/SITE INFORINIATION & ADDRESS
<br />1. Record name mid ad€i;vss (physical loci, 60n) of the a dear:?€.s t1 fatal (si.
<br />NOTE: Address MUST have a valid phvsicad Iocartior incluciit_z city, state. and zip Cade.
<br />P,O} BOX NUMBERS ARE NOTACCEFTAB1, 1,
<br />Include nearest cress street and narre of'the €spec&°ic—,
<br />2. Phone: number roust have an area code. If'tise t€igirt number is tr w s toe. write `SA vS%:;°' in proper ls'catic€ z.
<br />3. Check the appropriate boy for "TYPE OF BUSINESS OWNERSHIP lux. CORPORATION, INDIVIDUAL, etc,).
<br />-. Check the appropriate box for "TYPE OF BUSI`IENS.
<br />5_ If Facility/Site is located within an Indian reservation or cxhor Indian trout lards, check the box maarRed "YES"
<br />Ci_ In fcate the NII�IBE:R ofTANKS at this SHT,
<br />7. Record the E,P,A, ID Of or write "NONE" in the space provica=rd.
<br />II_ PROPERTY OWNER INFORMATION & ADDRESS (NIUS-1 BE C:'OM z - a E;f
<br />Cc=r tkese til item� Ct'on. unless all itemsam the sarne as sT" r€,c .i i AS SITE" across this section, Be sura
<br />to check PROP :;"< `JWNERSHIP TYPE box,
<br />Ill. TANK OWNER ` MATION & ADDRESS (MUST BE COMPLETED"
<br />Cart€plots: all ar z i., section. unless all items are the saoie as SEC"I'lON i.._ .,... , ��-a�,:L ;,AME' AS aITE" across this secti€.€n. Be sure
<br />to check TANK,. ()W.- QRS TYPE. bex,
<br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT S3E AR'I ICrL.E 5. CIiAl"rEIt 13.75.
<br />DIVISION :.0, C,ALIFORNNIA HEALTH AND SAFETY CODE,)
<br />Enter your .Board of Equalization (BOE) UST storage fee account number which is icqui€ed before your perrnit application can be processed.
<br />Registration with the BOB will Insure 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 LISTS. The BOE will code pm, -ors exempt from paying the >tornge fee so returns will not be sent. If you do not have an
<br />account number with the BOB or if you have ;any quesm4is regarding the fee or exemptions, please Bail the. BOB at 916-322-96669 or write to the.
<br />BOB at the fallowing address board of Etlualiz>tio , Fuel Taxes Division. 11.0, Box 91-2879, Sacramento, CA 941-79-0001,
<br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY (MUSTBE COMPLETED FOR PETROLEUM T. STs ONI...Y, SET; SECTIONS 2711 (a)(I 1)
<br />OF TITLE 23, CHANTER 16, CALIFORNIA CODE OF REGULATIONS,)
<br />Identify the method(s) used by the owner andlor operator. in i meting the Federal and State financial responsibility regniresnents. USTs awned by
<br />any Fee{eral or State 'agency as well as €tern-pcLmliuma USTs arc exerript from this requ;rcmcnt.
<br />VI. LEGAL NOTIFICATION AND BILTANG ADDRESS
<br />Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLINGS NOTIFICATIONS,
<br />TANK. OWNER OR AUTH(,)RI.ZF:i3 REPRESENTATIVE M. u sT smNz AM DATE TI IE FORM AS INDICATED, (SEE SECTIONS 2711
<br />(a)(13) OF TITLE 23 CHAPTER 10, CALIFORNIA CODE OF REGULATIONS.[
<br />INSTRUCTION FOR THE LOCAL AGENCIES
<br />The county and jurisdiction numbers are predetermined and can be obtained by callinT the State hoard (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 />pri tit", the State Board to assign (lie facility number, please leave it bla€ik.
<br />IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACII_ITY TO VERITY THE ACCURACY OF THE
<br />INFORMATION, TI -IIS APPLICATION CANNOT BE FROCESSED IF TIII--.13OE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL
<br />AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE; "LOCAL AGENCY USE ONLY" INFORMATION BOX. THE LOCAL
<br />AGENCY SHOULD RETAIN T14E ORIGINAL AND YELLOW COPIES. THE,' TINY COPY SHOULD BE RETAINED BY THE TANK
<br />OWNER.
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