COMPLIANCE INFO_1986-2001 - Laserfiche WebLink

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TU 4 INS'Ci2UCI1ONS 11OR C.",OMP11,1ING TUBI A* GENERAL INST'RUCT'IONS: L One FORM "A" shall be completed for all NEW PERMYIN, PERMIT CIIANG or any FACIIXINISITIi INIk)I A11ON CIIANGF_S. 2 SUBMfr ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at tile, sire. 3. This forin should be completed by either the PE-kMFI. APP1JCANr or the LOCAL AGENCY UNDI.RGROt ND TANK ltd aPEX7.1X)I.. 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies: OP OF PO "MARK ONLY ONE.H M" Mark an (X) in the box next to the item that best describes the reason the form is being completed. 1. FAC1I I1-Y/Srl i INFO HON & ADDREFS (MUST BE COMPLI:IIiD) L 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 NO`T`A ABIY Include nearest cross street and tzarne of the operator. 2. Phone number must have an area code. ll 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 srrE. 7. Record the E.P.A. ID # or write "NONE" in the space provided. IL PROPEItIY OWNER INVORMAI"ION &ADDRESS ( J51'BE COMPLI?I D) Complete all items in this section, unless all items are 0he same as SECTION I; if the sante, write ".'SAME AS SrIV across this section. Be sure to check. PROPERTY OWNERSHIP 'TYPE box. III. TANK OWNER . X)RIVINHON &ADDRESS (MUSTBE CC'MPLUMD) Complete all iters in this section, unless all items are the sante as SEC CION 1; If the same, write ".;AMI;AS srm, across this section. Be sure to check TANK OV446MITP TYPE box. IV. BOARD ,01F MUALMAMON USI'STORAGE HiE ACCOUNT NUMBER(MUST BE C.OMPidil 0) Enter your Board of Equalization (BOE) US'I` 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 $0. (6 mills) per gallon fee due on the number of gallons placed in your U5I's. The BOE will code persons exempt from paying the storage fee so returns will not be sent. If you do not have an account number with the BOE, or if you have any.. questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE:'at the followih- address: Board of Equalization, Environmental Fees Unit, P.O. Box 942$'79, Sacramento, CA 91279-0001. V. PI3TROLF?UM UI;F N L '�'SPONSIB 81'BE COMPI.1i"ITI)) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. US`Is owned by any Federal or State agency are exempt from this requirement. VI. LEGAL NO'1111'10VI"ION AND B111.ING A1Js31bESS . Check ONE BOX for the address that will be used for I30'I'II LEGAL AND 1111,11146,NOITIaTC AI10lNS. AppucAlvr MUST SIGN AND DAV,THE FORM AS INDNWIV11 4N,I'RUC ION FOR TIIL I.00:A'L ACiF.le100S The county and jurisdiction numbers are predetermined and can be obtained by calling"the State Board (916)734-242"1. The facility number In�xtay be assigned by the local agency; however, this number rust be numerical and cannot contain any alphabetical. Wthe local agency prefers the State Board to assign the facility number, please leave it blank. IT Is ri IIs OF`111V t.(;t:A`, /61INC`Y THAT INSPECI`S 1I11;FACIL IY°1'O VIMFY.111E ACCURACY OF''ITIE€NFORMMION, '11115 APPL=IC A"I ON CANNOT BE PROCESSFI) IF THE 130E ACC OUN F NUMBER IS NOT FILLED IN TTiI,: LOCAL AGING`Y IS RESPONSIBLF FOR TTNB COMPLFI'ION OF oD°I1'E "LOCAL AGENCY USE i3N,VY' 1="iFORNIND.?N BOX AND FOR FORWARDING ONE FORM "A"ANIS ASSOICIATF13 FORM "B"(s) TO LtLI;17011,0WING ADDRFS& STATE? OF CAI,IFC)RMA FFAlU WNI'ER RI"l,(_)URC VS C;ONFROL BOARD PARAMOUNf, CA 90723