COMPLIANCE INFO_1997-2002 - Laserfiche WebLink

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INSTRUCT IONS FOR COMPI.>a ftRM A" GENPRAI, IN,5l'R T ,. ONS: 1. tired DORM "A" shall be completed for all NEW PERMITS, PERMIT CIIANGES or any FACILIi'Y/SI1V INFORMATION } SUBMIT ONLY O � Site y/, regardless t t re rdless of the number of tanks located at the site, 3. 'll his form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROIAD TANK INSPECTOR is-pe or ptint clearly all requested information. instrument, you are making 3 copies. Use a hard point writing `1701' C'F C)R>M: "MARK ONLY ONE :Mark an (X) in the box next to the item that best describes the reason the form is being completed. 1. FACILII 'jSI)CE INF,0RMA370N&ADDRESS (MUST BE COMPI..ETED) 4,..,t I. Record name and address (physical location) of the underground tank(s). NOTE: Address MUST have a valid physical location including city, state, and rip code. P.O.BOX NUMBERS ARE NOT ACCEPTABLE. 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 locatt'oh 3 Che k.the appropriate bbx for TYPE OF BUSINESS OWNERSHIP (ex. CORPORA'T'ION, 1NINVIDUAI.. 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". 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 pit ADDRESS (MUST BE COMPLE'1"E1)) Complete all items in this section, unless all items are the same as SECTION 1: if the same, wTite "SAME' AS Srh,'- across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. TANK OWNER INFORMAWN A.,-,ADDRESS (MUST.BE COMPLEII-11)) t Complete all items in this section, unless all items are„the same as SECTION 1: If the same, write "SAi4IE AS sIIT”across this section. Be sure to check TANK OWNERSHIP TYPE box. FV; BQARD 017 EOUALTZKI-ION.;UST%-ORAGE FEE ACCOUNT NUMBER (MUST BE COMPLLr119)) Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application can be processed. Registration with the BOB will ensure that you will receive a quarterly storage fee return in reporting the $0.006 (6 mills) per gallon fee due on the number of gallons placed in your US"Ts. The BOF will code persons exeml)t from paying the storage fee so returns wiA':nbt-'lie:. ent. If you do not have an account number--with'ilii!j3()$."or ifyou tl 3vc,°ttliy.',, questions regarding the fee or exemptions, please call the BOB at 916-323-9555 or write to the BOE at the followim-, i 1 rc,;s: Board of Equalization, Environmental Fees Unit, P.O.:Box 942879, Sacramento, CA 94279-0001: R V. PE OLEUM UST FINANCIAL RESPONSIBILITY (MUST BE COMPLETED) , .. , '4 Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility tequirements. USTs owned by any Federal or State agency are exempt from this requirement. VL I EXIAL NOTIFICATION AND BICI,ING ADDRESS t' Check ONE BOX for the address that will be used for BO'1'H LIX;AL AND BII.IING NOTIFICATIONS. APPLICANT MUST'SIGN AMD DATU THE FORM AS INDICATED. INSTRUCTION FOR THE,LOCAI.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 prefets the State Board to assign the facility number, please leave it blank. IT IS THE .RESPONSIBII.ITY OF TIM LOCAL AGENCY 'THAT INS'PECIS THE FACILITY T() VERIFY TTIE ACCURACY OF THE INFORMATION. THIS APPLICATION CANNCYI'BE PROCESSED IF ITIS.BOE AC:COUNI` NUMBER IS NOT F11J,FD IN. [ITE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPL BON OF THE 'LOCAL AGENCY USE ONI Il'MI0SATT�(3N :i£ AND FOR FORWARDING ONE? FORI4�'"A":A�IQ f„' ASSOCIATED MRM "B"(s) TO 'IIIE FOLLOWINfi ADI)RFSS. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O S.W.E E P S. DATA PROCESSING C,'I.NFER P.O. BOX 527 PARAMOUNT, CA 90723