COMPLIANCE INFO_1991-2000 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM W GENERAL IN',VIRUCITONS: 1. One FORM "A' shall be completed for all N11W PERMI'VS, PERMIT'CIL4%NGIN or any FACH11,Y/SITF, INI?ORMX11ON CHANGES. 2. SURMrF ONLY ONE (1) JURM "A' for a Facility/Site, regardless of the number of tanks located at the sito% 1 This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDFIRGIZOIJND TANK tNSP14X-J'OR. 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM. 'MARK ONLY ONE ITEM" Mark an (X) in the box next to the item that best describes the reason the form is being completed. 1. FACJLrI-Y/SrJ7E INI-ORMKIION & ADDRM. (MUST BE COMPLIiTED) 1. Record name and address (physical location) of the underground tank(s). NOTE: Address ,MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARE NOTACCUFTABLE. Include nearest cross street and name of the operator. 2. Phone number must have an area code. If the night number is the same, write "SAME" in proper location, 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INI)IVIDUAI_ etc,) 4, Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YFS". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A. ID # or write "NONE" in the space provided. H, PROPEKI-Y OWNER INFORMN171ON&ADDRESS (MU9r BE C()MPLHnff3) CA)mplete all items in this section, unless all items are the same as SECI'ION 1; if the same, write '.SAME AS srni." across this section. Be sure to check PkOPERTA' OWNERSHIP TYPE,' box, Ill. TANK OWM:,,R INFORMAIION &ADDRESS (MUST BE COMPILqvD) Complete all items in this section, unless all items are the same as SECTION 1; If the same, write *SAMI:`1 AS Srlli*across this section. Be sure to check TANK OWNEIL911P TYPE box. IV. BOARD OF EQUALIZATION UST.STORAGE FEE.ACCOUNT NUMBER(MUST BE COMPLIMED) Enter your Board of Equalization (BOE) usr storage fee account number which is required before your permit application can be processed. Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the $0.006 (6 mills) per gallon fee due on the number of gallons placed in your UST's. The BOB will code persons exempt from paying The storage fee so returns will not be sent. If you do not have an account number with the BOE" or if you have any questions regarding the fee or exemptions, please call the BOE at 916-32.3-9555 or write to the BOE at The following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PE1`ROLFUM U."M FINANCIAL RESPONSIBILITY(MUST BE COMP11-ri-T.-D) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. US`Fs owned by any Federal or State agency are exempt from this requirement. VI. LEGAL NO11FICAHON AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BELJJM NOTIFICA'ITONS. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INS1'RUCI1ON FOR THE LOCAL AGENCIE.S The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-242'1. The facility number may be assigned by the local agency; however, this number must be numerical and cannot contain any alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank. 117.11'IS'111E RIHNPONSIBILITY 017 T111111 LOCALAGENCY THAT INSPEC'M ITIE FAC 111 TO VERIFY'171F.- ACCURACY OF THE INFORMATION. '1111IS APPLICA'FION CANNOT B13.PROCESSED IF THE DOE ACCOUNT NUMBER IS NOT FILLED IN. 'ITIF LOCAL AGFNCY IS RESPONSIBLE FOR THE COMPLETION OF TIH! *LOCAL AGENCY USE ONUY" INFORMATION BOX AND FOR FORWARDING ONE FORM *A*AND ASSOCINIVID FORM -B-(s)TO THE FOLLOWING ADDRESS. STATE OF CALIFORNIA STA`117 WATER RESOURCES CONTROL BOARD C/o &w.I1F_P.& DATA PROCESSING CENI'ER P.O. BOX 527 PARAMOUNT, C.A.90723