|
INSTRU0IONS FOR. COMPLETING FOM "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECT ION 2711 OF TITLE 23,CHAPTER 16,CALIFOP-\IA CODE OF REGULATIONS AMID SECTIONS 25286,25287,AND 25289 OF CHAPTER
<br /> 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS.I'O"APPLY FOR AN UST OPERATING PERMIT.
<br /> 1. One FORM"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 UNDF'RGROUND TANK INSPECTOR.
<br /> 4. Please type of 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 2711(a)(8),CCR].
<br /> T 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)()1),CCK].
<br /> TOP OF FORM:"MARK ONLY ONE ITEM"
<br /> Mark an(X)in the box next to the it.ent that best describes the reason the font is being completed.
<br /> 1. FACILITY/SITl3'fNFOI2tti4A'II0N&ADDRESS(MUST"BE COMPLETED)
<br /> i. 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 NUNIBERS ARE NOT ACCEPTABLE.
<br /> Include nearest cross street and name of the operator.
<br /> 2. Phone number must have an area code. I.f the night number is the same,write"SAME.."in proper location.
<br /> 3. Check the appropriate box for TYPE OF BUSTIN E.SS OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4. Check the appropriate box for TYPr OF BUSINESS.
<br /> 5. If Fagdity/Sitc 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.14)#or write"NONE";n the space provided.
<br /> IT. PROPERTY OWNER INFORMATION Sr ADDRESS(IMUST 13E 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 OWj ERSIIIPT'YPI box.
<br /> 1.11.TANK OWNER INFORMATION&ADDRI:?.SS(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 OWNERS TYPE box.
<br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CIIAT l-ER 6.75,
<br /> DIVISION 2t),CALIFORNIA III.AI..TII ANI)SAFETY CODE.)
<br /> Enter your Board of Equatiration(B£.?E)USTstorage fee account number which is required b(.fore:your pem)it ap �ication care be processed.
<br /> Registration with the BOE will ensure that you will receive a quarterly storage fee retum in reporting the S0.tx)0((1nJ ; Pur glillon fee due on the
<br /> number of gallc€n placed irr your c''S1's. Tlrc 1301:?will code persons exempt from paying the storage fee so ut ., 1>c sera. If you do no
<br /> have an account number with the BOIL or if you have any questions regarding the,fee or exemptions,please call the 1I()!a at 9''6 32"9069 or%vritje
<br /> to the 1.301:at the iolto;a ing addr:!ss Board of Equalization,Fuel Taxes Division,P.O.Box 942979,Sac•ramcnto,CA 94279-01')t 1.
<br /> V. PE'IROLliU-M UST I-INANCIAL RFSPONSIBILITY(MUST TIE COMPLETLI)FOR IIIsl'ROLI.UNI USTs Is t)tiLY,SFF SF(:I"()NS 27,1 1 ta)`I
<br /> OFTITI E 23,CHAP z'Elt 16,CALIFORNIA CODE Ol RFGI'._A`IIONS.)
<br /> Identify the nuethcxl(s)used by tltc owner amIlor operator,in nw..;;tang the Federal and Stale financ,itrl z.c c,r: 1""T's r»5.�::::I by
<br /> any Federal or State agency as%vel.l as non-petroleum USTs are excinpi.from this roquiretnent.
<br /> VT.LEGAL NOTTFIC.ATION ANI)BILLING ADDRESS
<br /> Check ONE BOX for the address that will be used for BOLFI LEGAL AND BILLING NOTIFICATIONS,
<br /> NS,
<br /> TANK OWNER OR AUTI1ORILI?I)Rf PRI.SI;NI'ATIVE:tiIUS'l'SI£;N AND DATE THE FORM AS INDIC A bi:l). (51;1?S,O T ION} 27 11
<br /> 16,CA1.11,OR,NIA CODE OF REGULATIONS.]
<br /> INSTRUCTION FOR T1IE LOCAL AGENCIES
<br /> The county an jurisclictwn nurnikrs arc prceletcnneted and can he obtained by calling the State Board(916)227-4303. 'I'hc fzc,li';y€xrnbcr rrtay 1�
<br /> assigned by the local agency;however,this number trust be numerical and cannot contain any alphabetical characters. IF the local agency prefors
<br /> the State 13.oa€'d to assign the Facility number,please leave it blank.
<br /> -IT IS T'Hla RI;SPONSIBILIT'Y OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OF THE
<br /> INFORMATION. TI IIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED I.N. THE I..00AL
<br /> AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX ANI) FOR
<br /> FORWARDING ONE FORAI"A"AND ASSOCIATED FORM"B"(s)TO THE FOI..LOWING ADDRESS. THE LOCAL AGENCY SHOULD
<br /> RETAIN TTII., OR.K:rINALS AND FORWARD TIIE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> REI'AlNE1)13Y,1'IIF,TANK OWNER.
<br /> STATEOF CALIFORNIA
<br /> STATE W'AT FR RESOURCES CONTROL BOARD
<br /> .0/O S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 917723
<br /> 3193 FORtD12ORI
<br />
|