COMPLIANCE INFO_1984-2002 - Laserfiche WebLink

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IN',0RUCITONS MR COMPLE'11ARMA' 0 GENERAL IN',51RUCTIONS: 1. One FORM"A"shall be completed for all NEW PFIUAM,PERMrI'(1LANGI:7_S or any FACIm"Y/smi INFORMATION CIIANGKS. 1 SUBMrr ONLY ONE (1)FORM'A'for a Facility/Site,regardless of the number of tanks located at the site, 3. This form should be completed by either the PERMIT APP11CANr or the LOCAL AGENCY UND1.1111GROUND TANK IN,SPFCTOPL 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument,you are making 3 copies. TOP OF FORM:'MARK ONLY ONE II'LM® 1. Mark an (X)in the box next to the item that best describes the reason the form is being completed. 1. FACIIJI-V/SITE,INFORMATION&ADDRE-SS(mugr mi compiHrED) 1. Record name and address (phy$ical location)of the underground tank(s). NOTE: Address MUST have a valid physical location including city,state,and zip code. P.O.BOX NUMBER ARE NOT AccEPTABul- 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. 1 Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex. CORPORA71'10N, INDIVIDUAI.,-etc.) 4. Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Site is located on land within an indian reservation or other indian trust lands,check the box marked "YES". & Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A. 11)* or write ".\IONl. in the space provided. 11. PROPERTY OWNER INFORMATION&AD1)R0SS(MU,5r BE COMPIZ1111)) 1. Complete all items in this section, unless all items are the frame as SECTION 1; if the same,write *,SAME AS S1'1`E'across this section. Be sure vi check PkOI1ER'I-Y OWNEIRSHIP'.1"YPE box. III.`TANK OWNER IN", )RMATION&ADDRE-SS(MUS-I` IE COMPLuIED) t amiplete all items in this section, unless all items are the same as SEC 17ION 1; If the same,write "SAME.AS STni* across this section. Be sure to chcck'rANK OWNERSHIPTYPE,box. IV BOARD OF MUALIZATION USI'517ORAGE FEET ACCOUNT NUMBER COMP11110) Enter your Board of Equalization (1301'.)Usr 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 SWW) (6 mills)per gallon fee due on the number of gallons placed in your UST's. The BOE will code persons exempt from paying the storage fee so returns will not be sent. If voiu do not have an account number with the BOV11 zor if you have any qucstions regarding the fee or exempzions,please call the BOF,at 916-719-2592 or write to the BOE at the following address: Board of Equalization,Environmental Fees Unit, P.0, Box 942979,Sacramento, CA 94279-0,001. V. I1X;AI.NO11140VIION AND BILLING ADDRESS L Check ONE BOX for the address that will be used for 1OT11 LEGAL AND BIIJ.JNG N(MFICATION& APPIRDINI'MUS't'SIGN AND DNIT"THE FORM AS INDICATED. IN917RUCHON FOR 171H I AGENCIES The county and jurisdiction numbers are predetermined and can he obtained by calling the State Board (916)739-2121. The facility number may be assigned by the local agency; however,this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the facility number,please leave it blank. rr is,niji RJI.SPONSIBILITY OF11IF IX)CAL AGENCY TIIAT INSPECTS114E FACIMYTO VERIFY TIIE ACCURA(Y fJF'I7IE INFORMA1110N. '17115 APPI1CXI7ON cANNorr BE PROCESSED ti THE BOE ACCOUNT NUM11CP IS NOT TILLIN) IN. '111E LOCAL AGENCY IS RESPONSIBLE 17OR 111E COMPLETION OF 711E*LOCAL AGFNC'Y USF,ONLY*INFORNI)VIJON [IOX AND 1 FORWARDING ONE FORM"A'AND ASSOCIATED FORM THE FOLLOWING ADDRESS. OF CALIFORNIA S1Wf`E WUER RF-SOURCF-S(X)NTROL BOARD C/O sm.lui-P.S. DA'I'A PRO(MiSSING(1' R P.O.BOX S27 PARAMOUNT,CA 9TM