COMPLIANCE INFO_1986-1999 - Laserfiche WebLink

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INS RU(71710NS FOR C MI'l.l:11NG IX)RM"A" GENERAL IW172UCI1ONSe 1. One FORM"A"shall be completed for all NEW PERMTIS,PERMTI'CHANGE'S or any FACII1I'X/srim INFORMATION CHANCES. 2. SUBMTr ONLY ONE(1)'F ORM".A"for a Facilil'y/Site, regardless of the number of tanks located at the site. i 3. This form should be completed by either the P1�,RMIT APP11CANI'or the LOCAL AGENCY UNDERGROUND"TANK INSPWI'OR. 4. Please type or print clearly all requested information. S. Use a hard point writing instrument,you are making 3 copies. TOP OF FORM: "MARK ONLY ONE YI7W" 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. F. FACIITFY/STI'L MF ORMNnON&ADDRE&S(MUST BE CX)MPI1?'I1.1D) 1. Record name and address(physical location)of the underground tank(s). NOTE: Address MU517 have a valid physical lcwation including city,state,and zip code. P.O.BOX NUMBER ARE NOI'ACCI7I'ABl1? Include nearest crass street and name of the operator. 2. Phone number must have an area axle. if the night number is the same,write"SAN 4E"in proper location. 3. Cheek the appropriate box for TYPE O1"BUSIN1.3SS OWNERSHIP(ex.CORPORATION, INIAVIDUAL,etc.) 4. Check the appropriate box for'IYPE 01'BUSINESS. 5. if Facility/Site is located on land within an indian reservation or other indian trust lands,check the box marked "YES". 6. Indicate the NU'MBI3R of TANKS at this S1'E'E. 7. Record the E.P.A.11)#or write "NONE" in the space provided. ll. PROPERTY OWNER 1NFORMA`rI0N&ADDRESS(MIJSI'BE c oMPI1:rni,D) 1. Complete all items in this section, unless all items are the same as S1 CIION 1; if the same,write "SAME AS STI1?"across this section. Be, sure to check PROPERTY OWNE'RSHIPTYPI1 box. III.TANK OWNER INFORMA11ON&ADDRINS(MUSl7 BE(30MPl1?`m)) 1. Complete all items in this section,unless all items are the same as S1 CI`ION 1;If the same,write "SAME AS SrI13" across this section. Be sure to check TANK OWNERSHIP TYPE box. IV BOARD OFlTi(QUA117JVIION USI'STORAGE ITE ACCOUNI'NUMBER(MUST BE CoMPLLn )) f3nter your Board of Njualization(130E) U,17storage 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,Wy (0 mills)per gallon fee due on the number of gallons placed in your USTs. The 1301: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 130E at 910-739-2582 or write to the 130E at the following;address: Board of Equalization,Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. 11XIAL NWIFICA711{)N AND BILLING ADDRI SS 1. Check ONE BOX for the address that will be used for BOT11 LFGAL AND BILLING NCYII11CA71ONS. APPLWAN17 MUST SIGN AND INVIT'111E FORM AS INDI(WITI). IN,5rRIJCTION m)R`Pili?LO(:AL A£`,IrNCIE,s The county and jurisdiction numbers are predetermined and can be obtained by calling the Slate Boars) (916)739-2421. The facility number may be assigned by the local agency; however, this number must be vnumerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the facility number,please leave it blank. rr Is nm RI:tSPONsTBi1.. ry OF'I1Il:i 1.0". .AGENCY"11IAT INSPF.CIN 71IR FAC:I T Y TO VERIFY 11IE ACC:URAC:Y OF 11IE INPOPMNI1ON. 'I1IIS APPLiCATI{)N CANNC7I'BL:PROC I+SSF?i)Ili"I1IE i3{)f;AC C t)t3Nl' NUMBFA IS N(7r FI.I.I.El)IN. `111E LO AL AGINC'Y IS RESPONSIBLE FOR 111E(.'OMPLINION OF`7IF"LOCAL. AGENCY USE ONLY"INFORMA`11ON BOX AND ICOR FORWARDING ONE FORM"A"AND ASSOC7AITr.D FORM "B"(s)-1`0111E F OI.I.OWING ADDRESS. s vnz OF CALIFORNIA 517NIE WATER RES)URCI S C ON17tOI.BOARD C/0 S.W.I?Fp.S. DNA PROC.'IxSS7NG CP.NI133R P.O.BOX 527 PARAMOUNT,CA 9072.3