COMPLIANCE INFO_1984-1998 - Laserfiche WebLink

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INSTRUCTIONS �)R COMPLETING FORM "A" ' GENERAL,INSl RUCTIONS. FORM "A" shall be completed for all NEW PERMITS, PERMIT CFIANGES or any FACILrTY/srm', CIIANGES. 2. SUBMTY ONLY ONE (1) FORM "A* for a Facility/Site, regardless of the number of tanks located at tha: si3e_ �, r —— sl,:-Ad be completed by either the PERMIT APPI.A.ANT or the LOCAL AGENCY UNDFRGIZOLJND 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 FORM: "MARK ONLY ONE ITEM" ,14nrk an (X) in the box next to the item that best describes the reason the form is being completed. 1. FACII.,TI-Y/STYE. P07ORMAIION&ADDRESS (MUST BE COMP1E:1'ED) 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 ACCEPTABLL 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 OWNTRSIIIP (ex. CORPORATION. IiNDIVIDUAI.., 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 "YFS". 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 B17 COMPLETED) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write "SAME AS S1TIs" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. M. "TANK OWNER INFORMATION &ADDRESS (MUSI'BE COMPLETED) Complete all items in this section, unless all items are the same as SECTION 1; If the same, write *SAME AS srn," across this section. Be sure to check TANK OWNERSLIIP TYPE box. IV.. BOARD OF EOUM IZA17ON UST Sl'ORAGE FEE ACCOUNT NUMBER (MUST BE COMPII-311M) 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 1301; or it'you have any questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOF, 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 COMPLI3IED) 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. VI. LEGAL NOTMICA'IION AND BILLING ING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BERING NO11FICA TIONS. 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)739-2,121. 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 THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VF.RIIrY THE ACCURACY OF THE INFORMAITON. THIS APPLICA'T'ION CANNOT BE PROCESSED IF TILE BOE AC(X)UNI' NUMBER IS NOT FILLED IN. ITIE, LOCAL AGI94CY IS RESPONSH3LE FOR TIIE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCIATED FORM "B"(s)TO TIIE FOLLOWING ADDRESS. STATE OF CALIFORNIA STATE WR'I'ER RESOURCES CONTROL BOARD C/o &W.E.I?PS DATA PROCESSING C:FN TER P.O. BOX 527 PARAMOUNT, CA 90723