Laserfiche WebLink
r <br /> it <br /> UST CLAIM APPLICATION <br /> INSTRUCTIONS FOR PAGE THREE '! i <br /> i <br /> V. CONTAMINATED SITE DESCRIPTION <br /> This section is to be used to identify the site that has been contaminated and:where the corrective action is being (or will <br /> be)performed. i <br /> II <br /> A. Provide the site name or description (e.g. vacant lot, residence), and the site address. <br /> I B. Provide the name of a contact person who has access to the site. <br /> i <br /> i <br />' C. Provide the telephone number of the contact person where they can be reached during normal business hours. <br /> D. List the name of the county in which the site is located. <br /> I <br /> E. Provide the county code for this site (refer to Attachment C). <br /> F. Check the appropriate box to identify the current use of the contaminated site. Check more than one if the site is <br /> used for multiple purposes (e.g., farm and residential). If there have,been any changes in the use of the land since <br /> 1985, describe these changes in Section M. <br /> I G. Provide the claimant's Board of Equalization (BUE) number. This isl the storage fee account number and is shown <br /> on the Underground Storage Tank Fee Return Form which is filed with BOE. Most tank owners are required to pay i <br /> the fee for each gallon of petroleum placed in a tank on or after janjuary 1, 1991. <br /> f I I <br /> H. Check the appropriate box that best describes the use of the tank(s)Illon this site. <br /> I. List the date that the unauthorized release of petroleum was first d' venom at this site. <br /> ). List the date that corrective action was first initiated. Corrective action does not include the detection, <br /> confirmation, or reporting of the unauthorized release or the repair,1:1 <br /> upgrade, replacement or removal of an <br /> underground storage tank or its associated equipment <br /> K. Check the appropriate box to indicate whether u, not the corrective' action has been completed at this site, and if <br />' completed, list the date the local regulatory agency approved the closure of the cleanup activities. <br /> L. List each tank involved in the corrective action. If known, provide lithe State I.D. number (SWEEPS) and the number <br /> of the permit to own or operate issued by the local regulatory agency. List the capacity (in gallons), and the <br /> substance stored. Check the box if the tank has been removed and list the date of removal. Check the box if the <br />! tank has been replaced. <br /> M. Provide a brief description, in chronological order, of all activities rll fated to the unauthorized release, from the <br /> i <br /> discovery of the release to the present. Include a description of any corrective action underway and/or completed. <br /> Use additional pages as necessary. <br /> I i <br /> N. Attach a site map drawn to scale which includes a north arrow andidistances relative to the nearest public roads. ? <br /> VI. REGULATORY AGENCY <br /> The regulatory agency has the responsibility or authority for regulating underground storage tanks, is responsible for <br /> overseeing the cleanup of contaminated soil and groundwater. Refer to Attachment C for a listing of regional boards, city <br /> and county public regulatory agencies. <br /> A. List the name of the UST permitting agency f <br /> J <br /> B. Using Attachment C, list the local agency code. <br /> C. Identify the Regional Water Quality Control Board having jurisdictil'i n over the site. <br /> D. Using Attachment C, list the region number of the site. <br /> 'i <br /> li <br /> E. Identify the case number assigned by the regulatory agency. <br /> F. Check the appropriate box to indicate the lead agency providing oversight of the cleanup at the site, the name and ) <br /> III telephone number of the agency contact person. <br /> i <br /> I <br />