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INSTROJONS FOR COMPLETING &M "All
<br /> GENERAL INSTRUCTIONS:
<br /> SECTION 2711 OFTITLE.23,CIIAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAFFER
<br /> 6.7,DIVISION 2Q,CALIFORNIA IJI,,-.AUFI I AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERNf][T.
<br /> 1. One 1`0100"A"shall be completed for all NEW PEIUWT CHANGES or any FACILITY/SITE INFORMATION CHANCES,
<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 TANK INSPECTOR.
<br /> 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 UST9 with.respect to
<br /> buildings and IwAlmarks[Section 2711 (a)(8),CCR].
<br /> 7. Tank owner mk-t 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),CCRI.
<br /> TOP OF FORM:"MARK ONLY ONE I="A"
<br /> Mark an(X)in the box next to the item that best describes the reason the form is being completed.
<br /> 1. FAClI.FFY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED)
<br /> 1. Record narne 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.13OX NUMBERS ARF NOT ACCEPTABLE.
<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 13UiSI.Nl-',SS OWNERSHIP(ex.CORPORATION,INDIVIDUAL.etc.).
<br /> 4. Check the appropriate box for TYPE OF 13 USTNESS.
<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 /> T Record the ET.A.ID#or write"NONE"in the space provided.
<br /> 11. PROPERTY OWNER INFORMAJION&ADDRESS(MUST BF.COMPLETED)
<br /> Complete,all iterns in this section,unless all items are the carne as SECTION 1;If cite same,write"SANIE AS SITE"across this section. Be sure
<br /> to check PROPERTY
<br /> IIT TANK OWNER INFORMATION&ADDRESS(MUSTBE COMI`LFTFD)
<br /> Complete all items in this section,unless all itCTTIS are the same as,SECI'ION 1;If the sante,wrim"SAME AS SITU"acres,,-,this section. Be sure
<br /> to check`TANK 01VNL:RSTY'111:box.
<br /> TV,130AIZI)01;FQUALIZATION LIST STORAGEIIT:ACCOUNT NUMBER(MUST BE COINIPLFTI3D.SEE ARTICLE 5,CIIAI-I ER 6.75,
<br /> DIVISION 20,CALIFOLLXTA 111`.ALTII AND SAI"'T,-f Y CODE.)
<br /> Inter your Board of Ecjualization MOE)UST storage fee account number Which ii required ix,forc,you7 pennit application call he processed.
<br /> Rc,jNlra6,)n wi0i 11he B01"will CIBUIC that you will,receive quarterly storage f'02 Muni in rC[)<)nlillgthC$(',O"(i(i,iiiillN)pergill'on fee due on the
<br /> turns
<br /> numb clolj,,:dlc1ns-1 in your Us,is. '1111C BOL""ill code persons exempt from paying ilic—torage fee.so re nt. If YOU do not
<br /> not 17C 51
<br /> have,allaccount 71tir-113CI:with ffic BOJ'oy I'-you have any questions regarding the,Lee or please call the B01k at.916-322 9669 or write
<br /> ur the;1301:ut.tl:d ic>l.tov:ag address B<�ard of Iiyualiza{Tort,I�ucl't'a.xe Divisitxt,IY.C).t3ox 5':.8'i),Sacramento,Ca 94279-GO{)l.
<br /> V. PETIZ 0I.EUM IUST FINANCIAL..,LZ ESPONSI 13 ILITY(,;UST BE.CONIPLE,"FED FOR 111`.1 ROL "UM US"s ON I I:SE'(:'I IONS 2 7 11 (a)(5)
<br /> Idem 11 if y iho used by the owner and/or operator,in mecting the Fcdcral and State financial at i,,spon.,idblili Ly I cqu ilety-Wras U STs o*cI)cd by
<br /> VL LEGAIL N011 CATION AND 131 LL I NG ADDRESS
<br /> Check ONE BOX for tha address that will be used for B0111 LEGAL AND BILLING NOTIFICATIONS.
<br /> TANK OWNER OR AUTIR)RIZED RFUIRESENTATIVE Mt STSIGN AND DATE THE FORM AS INDICATED. [5I-11,SEC IONS 2711
<br /> (a)(13)OFTITLE 23 CHAPTER 16,CALIFORNIA CODE Or RLGULATIO'N'S.]
<br /> INS'lRU(711ON FOR THF LOCAL AGI-',NCII,*,S
<br /> The cowny all jurisdiction nunibcrs are predetermined and can be obtained by calling the State Board(916)227-4303. 'Tire facility number may be
<br /> assigned by the local agency;IiIm ever,this number must be numerical.and cannot contain any alphabetical characters. If the local agency prefers
<br /> the State Board to assign the facility number,please leave it blank.
<br /> IT IS Tlll.: RI'SPONSIBILFFY OF TITh LOCAL AGENCY THAT INSPECTS THE FACILITY "TO VERIFY THE ACCURACY OF TIDE
<br /> LNFORMATION. THIS A I'll 1,ICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. TITE LOCAL
<br /> AGENCY IS RESPONSIBLE FOR TliE 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 THE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE
<br /> RE"FAINED 13Y TILE"TANK OWNER.
<br /> STATE OF CALIFORNIA
<br /> STATE WATER RESOURCES CONTROL BOARD
<br /> C/O S.W.E.E.P.S.
<br /> DATA PROCESSING CENTER
<br /> P.O.BOX 527
<br /> PARAMOUNT,CA 90723
<br /> FORD12ORI
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