COMPLIANCE INFO_1989-2013 - Laserfiche WebLink

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INSFRUCnONS FOR COMPLPAING FORM 'A" GENERAL IN5.f`R1JC`I1ONS: 1, One FORM "A" shall be completed for all NEW PI.1RMr1S, PERmn,CIIANGES or any FACIIXI-YISITI," CIHANGEi. 2, SUMMrf ONVY ONE (1) FORM W fora Facility/Site, regardless of the number of tanks located at the sitc. 5. 'Ihis form slh,,nM be completed by either the PERMIT APPIJCANr or the LOCAL AGENCY UNQ.I1'1WJROL.JNl) TANK INSPECTOR. '4. Please type or print clearly all requested information. 5. 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 thel reason the form is being completed. 1. I7ACIIrrY/Sr1L? IMAORUK11ON &ADDRESS(MUST BLz &)MPM?I17b) 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 Wn'ACCEPTABLI13- 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 Vocation. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSIYIP (ex. CORPORKf'ION, INDIVII)UAL. 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 "YFS". 6. Indicate the NUMBER.of TANKS at this SITE. 7. Record the E.P.A. ID # or write 'NONE" in the space provided. It. PRopfwry OWNER]INFORMA170N&ADDRESS Sr(mu4F compumo) C6 mplete all items in this section, unless all items are the same as SECTION 1; if the same, write 'SAME AS SrIV,' across, this section. Be sure to check PROPERTY OWNERSI-11 P TYPE box. IH. TANK OWNER 1r0-ORMAI1ON &AD13RPSS (MUST BI?COMPLLM�D) Complete all items in this section, unless all items are the same as SECTION 1; If the same, write *SAME AS srru" a(�ross this section. Be sure to check 'J.ANK OW' TEEMS UP TYPE box. IV. BOARD OF WIJALIZA'HON UST SMRAGE ACCOUNI'NUMBER (MUS I'BE?coMPTI-51RD) Enter your Board of EqualNation (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 reporting the $0.006 (6 mills) per gallon fee due on the number of gallons placed in your UST'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 f, Or cNcmptions, please call The BOE at,916-.32.1-9555 or*-.hte-'to the BOE at the following address: Board of Equalization, Fees Unit, P.O. Box-942879, Sacramento, CA 94279-0001. V. PETROLEUM UST FINANCiAl, RSPONSHVAxry (musr im-coMpikin 3) 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 front this requirement: VI. Dt61\-INO'HFI(WHON AND B111 NG iu)DRESS Check ONE BOX for the address that will be used for B(Y1I-I IX9GAL AND BIWING NO'11fqCA`IIONS. APPJJCANT MUST SIGN AND DATE THE MRM AS INDICAIL41). VWIRV CON FOR THE IOCAL 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. rl' ISTTIV R14,SPONSIB11,11-Y 0F`II AV LOCAL AGENCY T14AT INSPFX,-.[.'S IIIE FACT=To VOUPY THE ACCURACY Ota I'llL 1INVORVIV110-N 1IRS aVPHCATION CANNOT BE PROCESSED IF III'E 13013,AC()OIJNT N't'%WffV FIR IS Nt 11 11]) IN, 10`1 C(AAL V;IiNCY IS RESPONSIBLE FOR 111H COMPLEMON 017 37IIA' 'L(-KAL AGI.NC'V I 1M; ONVY' 1414)k N4,N JION BOX AND FOR FORWARDING ONE FORM 'A'AND his SOCLAV11,0 FORM "t Y'ks"YO �,'OiIk-)WING ADDRFSS. SIWIV OF CALIFORNIA d,TATF 'WA I RFSOURCF-St CONTPOL BOARD I)A'I';% 'ROCSSI-NO CEWI-71',R V-0, 527 PARAMOUNI, (A 90723