COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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44 INSTRUCTIONS FOR COMPLETING FORM "A" GENERAL INSTRUCTIONS: I. One FORM "A" shat be completed for all NEW PERMITS, PERMIT'CHANGES or any FAC:IId'IY/Snu INFORMATION CHANGES. 2. SUBMIT ONLY ONE(1) FORM "A- for a Facility/Site, regardless or the number of tanks loeatCd dt,, the ,itc. I This form should be completed by either the PERMPT APHICAWi or the LOCAI,AGENCY UNDER(;ROt.!NU TANK INSPECTOR. 4. , Please type or print clearly all requested information. 5. Use a hard point writing instrument, ,you am making 3 copi..s. TOP OF FORM. "MARK ONLY ONE ITEM" Mark an (X) in the box next to the item that b,;st describes the reason the form is being completed. L FAC IIX Y/SITE INFORMATION& ADDRESS (MUST BE COM.PI MIR)) 1. Record name and address (physical loeatio:t) of the undergtaund tank(s). NOTE: Address MUST have a valid physical location including city, state, and zip code. P.U. BOX NUMBERS ARE NOT ACC1lT TABIJL 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 "YES". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A. ID # or write "NONE" in the space provided. 11. PROPERTY OWNER INFORMATION&ADDRESS (MUST BE COMPLL1110) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write ".SAME AS SLIT?" across this section., Be sure to check PROPERTY OWNERSHIP TYPE box. III. 'TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) Complete all items in this section, unless all items arc the same as SECTION 1; If the same, write ",SAME AS SI7I?" across this section. Be sure to check TANK OWNERSIIIP TYPE box. IV. BOARD OF EQUALIZATION UST.1;;1'ORAGE TEE ACCOUNT NUMBER(MUST BE COMPIHII:D) Enter your Board of Equalization (BOB) 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 USTs. The BOF_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 BOB or if you have any questions regarding the fee or exemptions, please call the BOE 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. V. PETROLEUM UST FINANCIAL RESPONSIBII,TI'Y (MUST BE COMPLEim) 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. VL LEGAL NOTIFICATION AND Bff1JNG ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BR.UNG NOTIFICATIONS. APPLICANT MUST SIGN AND DATE'IHE FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (91'6)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 111E, RESPONSIBILITY OF TIIE LOCAL AGENCY ITIAT INSPECTS'IME FACILITY TO VERIFY TIIE ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. TTIE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A"AND r ASSOCIATM FORM "B"(s)TO TTIE FOLLOWING ADDRESS. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O&WT_F.P.S. DATA PROCESSING CENIT3R P.O. BOX 527 PARAMOUNT, CA 90723.