COMPLIANCE INFO_1993-1998 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM"A" GENERAL INSTRUCTIONS: 1. One FORM "A" shall be completed for all NEW PERMPIS, PERMIT CIIANGI:S or any FA(';Ii.rrY/SI I1? 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 form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNI)F?RGROl.1ND TANK INSPECTOR. 4. Please type or print clearly all requested information. i. Use a hard point writing instrument, you are making 3 copi.s. 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. L FACIIITY/SITE INFORMATION&ADDRESS (MUST BE COMPLETED) 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 ACCEPTABLE. Include nearest cross street and name of the operator. 2. Phone number must have°8n area code. If the night number is the same, write "SAME" in proper location. 3. Check the appropriate-bt 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. IL PROPERTY OWNER INFORMATION&ADDRESS(MUST BE COMPLE-rM) f Complete all items in this section, unless all items are the same as SECTION 1; if the same, write 'SAME,AS SLIT:" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPILgM) Complete all items in this section, unless all items are the same as SECTION 1; If the same, write "SAME AS S1TTi" across this section. Be sure to check TANK OWNFIRSIIIP TYPE box. TV. BOARD OF EQUALIZA31ON UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLI31E0) Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application can be processed. Registration with the BOB 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 USTs. The BOB 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 BOB at 916-323-9555 or write to the BOB at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PETROLEUM UST FINANCIAL RESPONSIBILITY (MUST BE COMPL137170) 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. VL LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS. APPLICANTMUST SIGN AND DATE THE FORM AS INDICATED. INSI'RUCTION FOR THE LOCAL AGFNCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (9116)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 RESPONSMHXI'Y OF TIM LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY'ILII? ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOB ACCOUNT NUMBER IS NOT FILLED IN. TIII;LOCAL AGENCY 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. STATE OF CALIFORNIA FORNIA STATE WATER RESOURCES CONTROL BOARD C/O &WX!."S. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723 . i F