COMPLIANCE INFO_1992-2000 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPT,M- NG FORM W OBNERAL INSI'RUCnONS: 1. One FORM `W' shall be completed for all NEW PERMrl.',), PERMIT (11ANGES or any FAC'Ilrl'y/SITl,.. INFORMA7t1ON CHANGHS, suBmir ONLY ONE (1) FORM 'A' for a FacilitN,/Sitc, regardless of the number of tanks located at the site. I'his form should be completed by either the PFIRMIT APPLICANT or the LOCAL AGENCY UNDVIWROUND TANK INSPECTOR. 4. Please type or print clearly all requested information. ,J Use a hard point writing instrument, you are making 3 copies. 1XV OF FORAC "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 FACILrff/,STMI INFORMA-17110N,&ADDRESS (MUST'BE WMPLE119)) 1. Record name sand address (physical location) of the underground tank(s). NOTE: Address MUST'have a valid physical location :ncluding city, state, and zip code. P.O. BOX NUMBERS ARE N(Yr AC CErrABIlt 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. S. 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 srl'E-. T Record the E.P.A. ID # or write "NONE" in the space provided. 11. PROPERTY OWNER INFORMA711ON &ADDRESS (Mu,,;r BE COMPLVIV D) Complete all item in this section, unless all items are the same as SECYION 1: if the same, write "SAME Ag snl" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. 'TANK OWNER INFORM)VIION &ADDREss (musr BE compilaw) - Complete all items in this section, unless all items are the same as SECTION 1; If the same, write *SAME AS %fll-*across this section. Be sure to check TANK OWNERSHIP TYPE box. IV. BOARD OF EQUALIM11ON UST STORAGE FEE AccouNr NUMBER(musr BE (,'ompurlim) Enter your Board of Equalization (BOF) USF storage fee account number which is required b6ford'youtt 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 USA. 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 130E or if you have any questions regarding the fee or exemptions, please call the BOE at 91.6-323-9555 or write to the 1101," at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001, V. PETROLEUM u,,;r FINANCIAL RLsPONsiBILn-Y (musr BE compunri)) 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. V1. LEGAL NOTIFICATION AND BUI-M'4G ADDRESS Check ONE BOX for the address that will be used for BO`111 I.EGAL AND BHJJNCv NO'1111CA717ONS. APPLICANT MUST SIGN AND DS113`nIE FORM AS INDICATE. IN'.VMUCITON FOR THE LOCAL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. The facilitynumber 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 6cility number, please leave it blank. rr MT11E.RESPONSIBU-ITY OF'nff? LOCAL Atcumc—i 'niAT iNspEcIs'n-w FAcuxrY TO vERIFY 711E ACCURACY OF THIS INFORMATION. IMS APPLI(WIION CANNOT BE PROCESSED W 11M DOE ACCOUNT NUMBER IS NOT FILI.FD IN. 71IF LOCAL AGENCY IS RESPONSIBLE.FOR THE COMPLFnON 017 ITIE 'LOCAL AGENCY USE ONLY' INFORMATION BOX AND FOR FORWARDING ONE FORM 'A" AND ASSOCIATED FORM W(s) 1`0 111E FOLLOWING ADDRESS. STNI`E OF CALIFORNIA SrAIT- WA17ER RESOURCES 00NMOL BOARD C/O S.W.E.11m DATA PROCESSING (MWER P.O. BOX 527 PARAMOUNT, CA 90723