COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

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INSTRUCTIONS FOR COMT, 7LETING FORM "A" a-^ GENERAL INSTRUCTIONS: � ��°��'� = SFCI"ION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER - 6.7,DIVISION 20,CALIFORNIA HEALTH ANDSAFETY CODE REQUIRE OWNERS TO APPLY FOR AN USTOPERATING PERMIT. 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES. 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site. 3. This font should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UbIDERGROUND TANK INSPECTOR. 4. Please type or print clearly all requested informaticin 5. Use a hard point writing instrument,you are making 3 copies. 6. Tank owner must submit.a facility plot plan to the local agency as part of the application showing the Location of the USTs with respect to buildings and landmarks[Section 2711(a)(8),CCR). 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the application for petroleum USTs[Section 2711(aXI1),CCR]. :;,; TOP OF 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 1. FACILITY/SITE'INFORMATION&ADDRESS(MUST BE COMPLETED) 1. Record name and address(physical location)of the underground ienk(s). NOTE: Address MUST have a valid physical location including city,state,and zip code. P.O.BOX NUMBERS ARE NOT ACCEPTABLE. Include nearest cross street and name of the operator. 2. Phone number must have an arca 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. H, PROPERTY OWNER INFORMATION&ADDRESS(NIUST BE COMPLETED) k' Complete all items in this section,unless all items are the same as SFCIION 1;If the same,write"SAME AS SITE"across this sectio m. Be sure to check PROPERTY OWNERSHIP TYPE box. M.TANK OWNER I_'\'FOWMATIO;ti&ADDRESS(MUST BE COMPLETED) Complete all items in this section,unless all items are the same as SECTION 1;If the same_,write"SAME AS SITE"across this section. Be sure to check TANK OWNL'RS TYPL box. IV.BOARD OF EQUAI._L'LATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPL.LIT.D.SEE ARTICLF 5,CILAPTI'A 6.75, DIVISION 20,CALIFORNIA lltiALTII AND SAFETY CODE.) Inter your Board of Equalization(BOE)UST storage fee account number which is required before yourpemtit application-can be processcd, Registratwn with the 1301:will ensure that you will.receive a quarterly storage fee retum in reporting the SO.W6((mills)per gallon fee due on the number of gallous placed in your US1's. The BOG will code persons exempt from paying the storage fee so rcturns will not be sent. If you do hot have an account number with the BOE or if you have any questions regarding the fee or exemptions,please call the BOE at 916 322-9669 or write to the 1301:at the.follow ung address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0001. V. PI:i'IROI:I:-iUM us I'FINANCIAL.RFSPONSIBILITY(MUST BE COMPLETED FOR P13'FROLF.U;`I USTs OM-Y,SEE SFC IONS 2711 (a)(8) OF TFILG 23,CIiAPTER 16,CALIFORNIA COLI.:OF REGULATIONS.) Identify the rnethod(s)used by the owner and/or operator,in meeting th44-'ederal antt-�tate financial respun3ibility requttextitau.s LSTs i,w ywd by. any Fedcral or State agency as well as non-petroleum UST's arc exempt from this requirement. VI.LEGAL.NOTIFICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS. TANK OWNER OR AUTiIORIIED REPR!?,SENTATIVF..MUST SIGN AND bA^TETILE FORM AS INDICATED [SEE S1.CTIONS 27't 1 (a)(13)OF TITI.F.23 CIIAPI'ER 16,CALIFORNIA CODE OF REGULATIONS.) INS'IRUCTTON F'OR TLIE LOCAL AGENCIES The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number may be assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the local agency prefer the State Board to assign the facility number,please leave it blank. IT IS T111Rf SPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY'f0 VERIFY TTIE ACCURACY OF THE INFORMATION. TIRS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL AGLiNCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY S}IOUI.D RETAIN TIIE ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE RETAINED BY 111F TANK OWNER. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O S.W.E.E,P.S. DATA PROCESSLNG CENTER P.O.BOX 527 PARA. IOUhT,CA 90723