COMPLIANCE INFO_1986-2002 - Laserfiche WebLink

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INSTRUCIIONS FOR COMPLETING FORM "A7 GENERAL INSTRUCTIONS 1. 0-e FORM "A" shall be completed for all NEW PERMITS, PERMIT C711ANGIN or any FACILrry/srn., RM ATION CHANGES. 2. SUBMIT ONLY ONE (1) FORM "A' for a Facility/Site, regardless of the number of tanks located at the siic- Tliis for sl--uld be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR. 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. TOP OF FORNC- "MARK ONLY ONE ITEM" Mark an (X) in the box next to the item that best describes the reason the form is being completed. L FACIIXI-Y/SITE, DWORMATION&ADDRESS(MUST BE COMPLElF.D) 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 ACC1.7rABUL 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, INDIVIDUAL, 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 "J'I" 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A. ID # or write "NONE" in the space provided. H. PROPERTY OWNER INFORMATION&ADDRESS (MUST BE COMPLETED) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write 'SAMF AS SrJ`E* across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. U TANK OWNER INFORMATION & ADDRESS (MUST BE COMPLETED) Complete all items in this section, unless all items are the same as SECTION 1, If the same, write *SAME AS srni" across this section. Be sure to check TANK OWNERSJ[HP TYPE box. IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLUI-ED) 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 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 BOE 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 FINANCIAL RESPONSIBILITY (MUST BE COMPLUMID) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. USFs owned by any Federal or State agency are exempt from this requirement. VL LEGAL NOT114CAIION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BH.UNG NOTIFICATIONS. APPLICANT MUST SIGN AND DATE THE 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'[HE RESPONSIBILITY OF'11W LOCAL AGENCY THAT INSPECTS 171E FAC11,111'Y TO VERIFY 111F ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IFITJE BOR ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCIATED FORM 'B'(s)TO THE FOLLOWING ADDRESS. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O -.WJU--P-& DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723