COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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r e S°IRUCe"11ONS MR CryC)MI'I.EMING FORM "A" GENERALI SI'RLIC'ITO S 1. One FORM "A" shall be completed for all Pu I ,�PF?.Rmrr CIIANGh% or any FAC ILLI !'/!;f1'I. 2. SUBMrr ONLY ONE (I) Ik)RM W €or a Facility/Site, rc�4ardic,>s of the number of tans located at: the soc. 3. 'This form should be completed by either the PEW IT AP11,11CANT or the LOCAL AGENCY LIIVtII;I2<;IZi31`ND TANK INSPEC T°OTC . 4. Please type or print clearly all requested iruormation. 5. Use a hard ;point writing instrument ,ou arr. making 3 cop€,�s. 'IOP OF FORM. "MARK ONLY ONE, , s " Mark an (X) in the box next to the item that best describes the reason the form is being completed. I. I?AC:ILTh`Y/Sr T7 IWORMAITON & ADDRESS (MUS -l' BE C OMPI..E:I"hil ) 1. Record name and address (physical loco iorx) of the undergr unc' lank(s). NOTE,: Address MUST have a valid physical location inclu,ling eity, state, and zip code. P.O. BOX NUMBERS S ARE N `l:" ACC17FABIIL Include nearest cross street and name of the; operator. 2. Phone number must have 'an area code. If the night number is the same, unite "SAME" in proper location.' 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex, C;C9ItIpC, RSPION, INDIVIDUAL,, etc.) 4. Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Sibs is located within an Indian reservation or other Indian trust lands, check the box marked YE.S". 6. Indicate the Itil.JhiiBER of TANKS at this SITE. 7. Record the .t . ID o� write, "NONE",'iii the. sp e provld . .i�' H. PTCOPEICF"Y OWNER ff4W)RMXI10N & ADDRESS (MUST BE CCS IZ110) Complete all items in this section, unless all items are the sante as, SEC TION 1; if the sante, writes *SAME. S SFIV.* across this section. Be sure to check PROPERTY OWNERSHIPTYPE box. Ill. TANK OWNER INS) A-nON & ADDRESS(MUST BE COMPLETED) Complete all items in this section, unless all items are the: same as -SECTION I, :If .the same,,write ",' AS Snir across this section. 'Be wire to check TANK OWNEUMBP TYPE box. 'z " TV. BOARD OF FAWAIXZATION LIST 1?17O GE Ig 4,AC.C:C7UNT" NU R (MUST BF, CO Enter your Board of Equalization (BOE) USI'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 USI`s. The BOE will code persons exempt from paying the storage fee so returns will not be went. If you do not have ars account number w"i"th they BOE -or, if you have any " questions regarding the fee or exemptions, please call the BOE at 916-323k9555 or vy ite to tide BOB at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942579, Sacramento, CA 94279-0001. v. PETRoi,Eum LIST FINANCIAL C'I siBI . (mun BLI co nvo) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. LISTS owned by any Federal or State agency are exempt from this .requirement. VL LEGAL N(XITIZICA77ON AND B111ING ADDRESS Check ONE BOX for the address that will be used for BOTH LFGALD BffJJNG NO11111CATIONS. APPTICANT MUST SIGN AND DATI31HE FORM AS INDICATFD. INSTRUCE[ON FOR T[IEI LOCAL AGFNCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (91.6)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 LS 17fF RESPONSIBRI17Y CSF °11111 LOCAL AGENCY 'TfIAT INSPBM 11W, FACILM TO VERIFY 1W. ACCURACY OFTHE FC)IL 1"I0N. T[HS APPLICNIION CANNOT BE PROCESSFD IF 'ITIS DOE ACCOIJNF NUMBER IS NOT FILLED IN. 11W LOCAL AGENCY IS RESPONSIBLE FOR WE COMPLETION OF 11H! "LOCAL AGENCY USE: ONLY' INFOR II[ON BOX AND FOR FORWARDING ONE W AND ASSOC-7A119) FO "I;"(s) TO ITIE FOLLOWING ADDRESS. S'T fE OF CALIFORNIA S-rATE WNI'ER RESOURCES CONTROL BOARD C/o 5.. = z _5. DATA PROCESSING Cr ITR P.O. BOX 527 PARAMOUNI7, CA W723