COMPLIANCE INFO_2002-2010 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "A" GENERAL INSIRUCTTO.NS: 1. One FORM "A" shall be completed for all NEW PERMITS, PERMIT CIIANGVS or any FAC'II.rTY/srl'li INFORMATION CIIANGFS. 2. SUBMIT 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 APPLICANTor the` )CAI,AGENCY CJNDFRC;R0[JND TANK INSPECTOR 4. Please type or print clearly all requested information. S. Use a hard point writing instrument, you are making 3 copies. TOP OF FORAL "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 FAC HXrY/SnF.INFORMATION &ADDRESS (MUST BE COMPIHMD) 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 ACCIII"EFIBLI:. 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.lttn:*p4riate box for TYPE OFBUSINESS OW'�fsItSHIP (ex. CORPORATION, INDIVIL7TtAI., etc.) 4. Check the appropriate box for TYPE OF BUSINESS. 5. If facility/Sate is located within an Indian reservation or other Indian trust lands, check the box marked 6. Indicate the NUMBER of`:PA KS at this SITE. 7. Record the E.P.A. ID # or write "NONE" in the space-provided.- u. PROPERTY OWNER INFORMATION&ADDRESS.SS (MUST BE C:OMPT.EIT D) Complete all items in this section, unless all iterns are the same as SECTION 1; if the same, write "SAME AS SHV" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. TIL TANK OWNER INFORMATION &ADDRESS (MUST BE COMPL.L=),,. Complete all items in this section, unless all items arse the same as SECTION 1; If the same, write "SAME AS SITT across this section. Be sure to check TANK OWNIJt.SFtIP'TYPE box. TV. BOARD OF EQUALIZATION UST STORAGE FIX ACCOUNT NUMBER(MUST BE C:OMPI.T?1133), 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 rcfxlrting 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 BOT; or if you have any questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-OW1. V. PETROLEUM UST FINANCIAL N, IIM-Y(MUST BE COMPLETED) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. UST's owned by any Federal or State agency are exempt from this requirement. VI. LEGAL NO'T'IFICATION AND BR G ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND E DI M NOTIFIC:A'TTONS. 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)739-2421. 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 THE RESPONSIBHXrY OF TIB3 LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY111E ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF TRE BOF?ACCOUNT NUMBER IS OOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF TIIE g1)CAL AGENCY USE ONLY" INFOILMATION BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCIATED FORM "B"(s)TO TME FX)LLOWING ADDRESS. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/o&Wju?Ps. 13ATA PROCESSING CENT ER P.O. BOX 527 PARAMOUNI, CA.90723 moi