COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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;Y " 946TRUCTIONS FOR COMPLY11ING FORM"A" GENERAL INSTRUCTIONS' 1. One FORM "A" shall be completed for all NEW PERMITS,, PI71.M17T CHANGES or any FACILn-f/Sriv. INFORMATION CHANGES. 2. SUBMIT ONLY ONE(1) FORM "A" for a Facility/Site, rcgardlc:ys of the number of tanks located at the site. 3. This form should be.completed by either the PERMIT APPLIC N`I'or the LOCAL AGENCY UNDERGROUND T INspecTOR 4. Please type or print clearly all requested information. Use a hard point writing instrument, you are making 3 copies TOP OIr FORM: "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 FACILITY/SITE II FORMATION&ADDRESS(MUSK BE COMPLBWD) 1. Record.name and address (physical location) of the underground tank(s). r 1 NOTE Address MUST have a valid physical location inclu,ling city, state, and zip code, Po. BOX NUMBI? ,ARE NOT ACawrABI.ti a 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 *propri#te 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. Ill # or write "NONE" in the space provided: II. PROPERTY OWNER ENItORMAMON&ADDRESS(MUST BE COMPI.Lr1`F.D) Complete all items in this section, unless all items are the same as SECTION 1; if the same, wrise "SAME AS,SrI11*"ttrross this section. Be sure to check PROPERTY OWNERSHIP TYPE box. IIL TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLUTMD) N. Complete all items in this section, unless all items are the same as SECTION 1; If the same write."SAME AS.S[I'E" across this section. Be sure to check TANK OVINEM-11P TYPE box. IV. BOARD OF EQUALIZATION UST STORAGE FEE.ACCOUNT NUMBER(MUST BE C_'OMPE.ErM) 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`wifh the BOB or if you have any questions regarding the fee or exemptions,please call the DOE at 916-323-9555 or write to the BOB at the following address: Board::of Equalization, Environmental Fees Unit, P.O.,Box 942879,Sacramento, CA 94279-0001. m V. PETROLEUM UST FINANCIAL RfiSPONSIBU ITR (MUST BE COMPLImI D) L Identify the method(s) used by the owner anti/or operator in meeting the Federal and State financial responsibility f requirements.. USTi.owned by any Federal or State agency are exempt from this requirement. VL LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE DUX for the address that will be used for BOTH LEGAL AND BII -JNG N(YI`IFlC.ATIONS. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR 1IJE LOCAL AGENCIES 'Y'l q-county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. •The' facility number)nay be,assigned by the local agency;however, this number must be numerical and cannot contain any alphabetical. E the local'agency prefers the State Board to assign the facility number, please leave.it blank. IT IS TIIB XHWONSIBII.r1'Y'OF TIIE LOCAL AGENCY THAT INSPECIS11JE FACIIaTY TO VERIFY TIIE ' ACCURACY OF TETE INFORMATION. THIS APPUCA11ON CANNOT BE PROCESSED IF THE DOE ACCOUNT - NUMBER IS NOTLLED IN. THE LOCAL AGENCY IS RESPONSIBLE FOR TALI COMPLETION OF THE AGENCY UE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM "B"(s)TO 17HE FOLLOWING ADDRESS _ SLATE OF CALIFORNIA SPATE WATER RESOURCES 00NTROL BOARD C:/O`&W.E.I & , DATA.PROCESSING CENTER P.O. BOX 527 a >('ARAMQUNT,.CA W11P y ,y