COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

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DISI"RUCTIONS I JR COMPI;I?TTNCi I'ORM "A" GIM:?RAL 1N51'RUC."TIONS: �a 1. One FORM "A" shall be completed for all NE.W PERMITS, PERMIT C"II13NGI r or any FAC'1i.xry/STi't"s INFORMATION CIIANGES, 2. SUBMIT C?.ivLY ONE (2) ESO 'A° for a Facility/Site, regardless of the number of tangs located rpt t� 3. This form should be completed by either the PERMIT APPLICAM or the LOC'Al.AGENCY L7 N13IiRGIi IOCND "TANK INSPECTOR. 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are malting 3 copies. TOP OF FORM:- "MARK ONLY ONE 11E?M" Dark an (X) in the box next to the item that best describes the reason the form is being completed. I. FmiurYjsrm INMRMKnON &ADDRms (MUsr ESB C:C)MPLE?rE=.I7) 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 ACCT7J:AEICC Tr 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, INF)IVIE)UAI.,, 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 "YES". fa. Indicate the NUMBER of'TANKS at this SITE. 7: . Record the F.P.A. ID # or write "NONE" in the space provided. B. PROPHRI"Y OWNER INITORMA717ION&ADDRGSSS (MUST BE COMPLETED) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write 'SAME,AS SrIT' across this section. Be sure to check PROPEW.rY OWNERSHIP n. PE box. III. TANK OWNER INF()RMA71TON BSc ADDRESS (MUST BE MPL-,rE)) Complete all items in this section, unless all items are the same as SEC HON 1, If the same, write "SAME AS SITE across this section. Be sure to check TANK OWNER'zalIP TYPE lox. IV. BOARD OF GQUATIM1ION USTFFORAGE FFE?AC'C:OUNr NUMBER (MUSE'BE C oMpurl-r ) Enter your Board of Equalization (BOE) UST 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 to reporirrrs4 the 10.006 (6 mills) per gallon fee due on the number of gallons placed in your UST's. The BOF will code person, escrnpt from paying the storage fee so returns will not be sent. If you do not have an account number with the BOT: or if v:w tIK:="t: atay. questions regarding the fee or exemptions,please call the BOE at 926-323-9555 or write t6 the BOIL+ at the follow-in, address: Hoard of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PPI"ROLEUM UST FINANCIAL RE:SPONS'II UXff (MUST BE C"O LE 1"L:.I)) Identify the method(s) used by the mr ner 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. VI_ 11:1GAI, N(Y1714CATION AND BIU-ING ADDRESS Check ONE BOX for the address that :will be used for BOTH LIX AL AND BILLING NOMITC ATIONS. APPLICANT MUST SIGN AND DATE THE' FORM AS INDICA`1'F,T). INSITCUCIION FOR•.ITIE?I)C.AL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)?39-2421. The facility number may be assigned by the local agency, however, this number must be numerical and cannot t>ntam anv alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it Blank. TI'IS` TIR RISPONSIBIIXff OF 111P LOCAL AGENCY 114AT INSPF, ,%'ITIE FACILITY TO VERIFY IFY 1111! ACCURACY C"Y OF THE INFORMATION. '1111,S APPI.,ICA'IION CANNOT BE PROCESS I) IF 1I1F? E AC'('OYINI" NUMBER IS N01' FILLET) IN. 17113 LOCAL AGMCY IS RE sPON%113111 FOR71IF COMP,F-1101 Ole 771E *LOCAL AGENCY USE; ONLY" I I$ORMAIION BOX AND FOR FORWARDING ONE 10 RM "A" AND ASSOCIAIED FO 'W(s)TO THE FOLLOWING ADDRESS. STA1T,OF CALIFORNIA STATI; WATER RESOURCES OUR N'ROL PA)ARD C/O DATA PROCUSSING CE R P.O. BOX 527 PARAMOUNT, CA 90723