COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "A! GENERAL INSTRUCTIONS: 1, One FORM "A" shall be completed for ail NEW PERMITS, PERMFI' CIIANGES or any FACIIXI'Y/SITE INFORMATION CTIANGES. ., ty/Site, reprollsof the number esof tanks located in thcs-iw. 2, SUBMIT ONLY ONE (1) FORM W for a Fac�h 3. This form should be completed by either the PERMIT APPLICANI'or the LOCAL AGENCY 1.1NlWIZGR0l!M) TANK INSPECTOR. 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 ITEM' Mark an (X) in the box next to the item that best describes the reason the form is being completed. I. FACILITY/STIR INFORMATION &ADDRESS (MUST BE COMPLETED) 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 NOT AccmAmi. 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 far'TYPE: OF BUSINESS OWNERSHIP "ex. CORPORATION, INDIVIDUAL, etc,) 4. Check the appropriate box for TYPE OF BUSINESS. S. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES". 6. Indicate.the NUMBER of TANKS at this SITE. 7. Record the E.P.A. ID # or writq,"NONE".in the space provided. It.' PROPERTY oWM3R INFORMATION&ADDRESS (MUST' B13 COMPIZI-ED). Complete all items in this section, unless all items are the same as SECTION 1; if the same, write "SAME AS srrf" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. TANK OWNER INFORMA11ON & ADDRESS (MUST BE COMPLH`ED) Complete all items in this section, unless all items are the same as SECTION 1; If, the same, write "SAME AS Sul' across this section. Be sure to check TANK OVJMRSIIIP TYPE box. IV. BOARD OF EQUAL17WITON UST!;rORAGE FFF ACCOUNT NUMBER (MUST BE COMPIIrIM) Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit apf)licalion 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 USTs. The BOE 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 BOF or if you have any questions regarding.the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PETROLEUM UST,FINANCIAI. RESPONSIBILITY (MUST BE COMPLEIM-D) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. USTs owned by any Federal or State agency are exempt from this requirement. V1. LEGAL N(YnFiCW11ON AND BILIING ADDRF:SS Check ONE BOX for the address that will be used for B`I1I LEGAL AND BILIING NO71113ICK11ONS. Appuc:Amr MUST' SIGN AND Dklll TIM FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. 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. IT IS'111E, RESPONSIBILITY OF 1111?LOCAL AGENCY THAT'INSPECTS 11111 FACILITY TO VERIFY UTE' ACCURACY OF THE INFORMATION. THIS APPIJ(W11ON CANNOT 13F PROCI::tSSED 1171HE BOE ACCOUNT NUMBER IS NOT FILLED IN. -11IF, LOCAL AGENCY JiS RESPONSIBLE FOR 771H COMPLETION OF TIIE *LOCAL AGENCY USI; ONLY* INFORMATION BOX AND FOR FORWARDING ONIR FORM "A'AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS. STATE OF CALIFORNIA SrWIV WATER RESOURCES CONTROL BOARD c,/O SmIums. DNIA PROCESSING CYWMR P.O. BOX 527 PARAMOUNT,-CA 90723 0