|
AOL
<br /> 0
<br /> LAST TRANSACTION REPORT FOR HP FAX-700 SERIES VERSION: 01. 03
<br /> FAX NAME:
<br /> INSTRUCTIONS FOR COMPLETING FORM "All 4 f i
<br /> DATE: 27—APR-99
<br /> FAX
<br /> 7— —
<br /> FAXNUMBER: TI 10. 16
<br /> GENERAL INSTRUCTIONS:
<br /> DAM SEAAM A NLu�t _
<br /> 27—APR I CIF . . {f 1 t7T t LATION A 4 � 25 � ._ 25289 C}p
<br /> C 7, tl h N R, �. . , � A L.a H AiND SAFETY`t�`ODE REQUIRE OWNERS TO :�, 4P AN[AT OPERA .'C3 PER, 4 1 16C
<br /> *********la C"co%I"k* ksa *litI Iiw Qlia�6Vd �j..x a a x w x x x*x x A*x
<br /> 2_ SUBMIT ONLY ONE(1)FORM„A"for a Facility/Site,re gardless of the number o 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 i bru'S r'.AX SENT
<br /> . t se a hard point wr ttny nstnaaaentei N(FA I VE )
<br /> 6. Tank owner r€aaast submit a facility past plan to a �� �X�I�!1 owing the location€f the USTs with respect to
<br /> buildings and hrndjnark [Section 2711 (a)(8), "
<br /> 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the
<br /> application for petroleurn USTs[Section 2 711(u)(I O) CC`RI.
<br /> TO PR I t+Tp� X(E� T ,WALLY, SELECT AUTOMATIC REPORTS IN THE SETT I NGS MENU.
<br /> TO PR I NTYthe TPRESS t ' n RERORT/ZPAGEaWTTM is b mPRESS ENTER.
<br /> 1. FACLLLTYISITfi'INFORMATION ADDRESS(MUST L?1I'c'ONZl'S,41TED)
<br /> 1. Record name and address(physical location)of the underground tank(s)-
<br /> NOTF,: Address MOST have a valid physical location including city,state,and zap code,
<br /> P.%.BOX NUMBERS BERS AIC^E NOT ACCEPTABLE.
<br /> Include nearest across sire a and nar.e of the of - wor.
<br /> 2. Phone number rxj:ushave pan a rL%,,,code. If the r ht number... .,_s.;nie, "SAME"in proper location.
<br /> 3. Check the appropriate box for TY"r',OF BUSING S OWNERSHIP(ex.CORPORATION,INDIVIDUAL,etc.).
<br /> 4, Check the appr prime Iso;for TYPT-'C F BUSINESS.
<br /> 5, If FachuylShe a locates within ars lodian resen,ation or other Indian trust Iands,chuck the box marked"YES",
<br /> 6. Indicate the NUMBER ofTANKS su,this S??7t
<br /> T Record the E.P.A.IN P or sashes"NONE"it the space provided,
<br /> ll. PROPERTY OWNER INFORMATION,&ADDRESS kMLST BE COMPLETED)
<br /> Com plate all hems in dors section,unless all henna ane the Same as SECTION I;If the same,write"SAME AS SITE"across this section. Be sure
<br /> to check PROPERTY OWNERSHIP IP TY PE box.
<br /> III.TANK OWNER 1 ;FC)igf,iA1ION Fl AIDDRESS I;S"tUS a BE COC lP F'IDLY;
<br /> Complete all items is this s,�.;<<on,r r=ccs all salsas a,_c,f.e same as.a1,,CTttaN 1;If the same,;write"SAME AS SITE"across this section. Be sore
<br /> to check TAMC OWNERS TYPE RL bee.
<br /> IV,BOARD Oto-EQUALIZATION UTP STORAGE FEE A �ClJ-N a NUMBER(NIUST BE COMPLETED,SEE ARTICLE 5,CHAPTER 6.75,
<br /> DIVISION 20,CALIFORNIA HEALTH,Il AND SAFETY ETY CODE.)
<br /> Enter your Board of Equalization MOE)US'!'storage;cc,ac-count r.urnber which is required before your permit application can be processed.
<br /> Registration crib ttae BOE will ea s�. ifi ct you wzil r.,�s e;a quartenystoage fee return in reporting the per gallon fee lase ata the number of
<br /> gallons placed in yowl-USTs, The BOE will code persons cxc a.pi,?c.,pray irg the sternage fee so returns will not be sent. I€yob db not have an
<br /> account noir bs.wash the BCE or if w ar have arty c a".Etions ae €ling the fee or exemptions,please call the 3307E at 916-322-9669 or write to the
<br /> BOEat th;it>!lo ing,adairess Boaz-i of Eq a,.zlaion,I e, ;.aaxas F.C.Box 42879,Sacramento,CA 94279-0001.
<br /> V. PETROLEUM UST FINANCIAL,RE`aPONSIBU L TY IN11.'ST BE COMPLETED FOR PETROLEUM USTs ONLY,SEE SECTIONS 2711 (at)(l l)
<br /> OF TITLE 23,CHAPTER 16,CALIFORNIA CODE O REGULATIONS,)
<br /> Identify the method(s)used by the owner ar llor operator,in meeting the Federal and State financial responsibility requirements.USTs owned by
<br /> any Federal or State agency as weds ;s nor apetrolca=r .S T°s are exempt from this requirement.
<br /> YT.LFf AL st TIFI°CA ICN `NT BILLING AIIT zrESS
<br /> Check ONE 13OX for the address,ss that will be usee for BOTH LEGAL AND FILLING NOTIFICATIONS.
<br /> TANK OWNER OR A[ fHORIZEI3 REFRa.SEN`L s-OVE MOST SIGN AND DATE THE FORM AS INDICATED, [SFE SECTIONS 2711
<br /> (a)(I3)OF TITLE 23 CHH T"ER 16,CALIFORNIA 4',ODE OF REGULATIONS]
<br /> INSTRUCTION FOR THE LCs""d AGENCIES
<br /> The county and jurisdiction€ irsbF rs a u predeterrnincd and can be obtained by calling the State'Board(916)227-4301 The facility number may
<br /> be assigned by he local al,r rcy>howeve ,tHs aaaamb a sriu t I _-oar rerical sad cannot contain any alphabetical characters. If the local agency
<br /> prefers the State Board iturnber,p; .zc leave it hark.
<br /> 1T IS THE RESP si,IBILI" ,,F THE > I A .t„La,o � ..T a. SMEC rs HE FACILITY TO VERIFY THE,ACC URACY OF THE
<br /> INFORMATION, THIS APPLICT:T ION C ANNOT°BE PlZCTC`BSSED IF THE BOB ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL
<br /> AGENCY IS RESPONSIBLE F°1TR THE C"aT'a-tl'a..ETION OF THE "LOCAL AGENCY USE ONLY” INFORMATION BOX. THE LOCAL,
<br /> AGENCY ,iPOULD RETAIN ae;F.ORI 4ITN,SL AND YELLOW COPIES, THE PINK COPY SHOULD BE RETAINED BY HE TANK
<br /> OWNER,
<br />
|