COMPLIANCE INFO_1987-1998 - Laserfiche WebLink

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INSURUC11ONS FOR COMPLE'17ING FORM "A7 GENERAL NSI'R iC'I'IONS: i, FORM "<A" shall be completed for all NEW PERMrIN, PERM17I7 CIIANGE:% or any FAC:iLWY/SFI'Vs 1 SUBMIT` ONLY ONE (1) FC) "A' for Facility/Site, regardless of the number of .tanks located at tltU size. old be completed by either the PPRMIT APPI.ICC.ANT,or the l,O(AI, ACII?N(Y L)''.NI)l?lC("tR 1F'Nl) TANK U14SEC;1<Cyit 4. Please type or print clearly all requested, information. 5, Use a hard point writing instrument, you are shaking 3 copies. P Cllr FORM- " RK ONLY ONE Mi tu,k an (:C) in the box next to the item that hest describes the reason the,form is being completed. T. FACJ.JrrY/SnF DdURMA7110N & ADDRE S ( I;r BE COP I 0) L Record name and address (physical location) of the underground tank(s), NOTE: Address MUST have a valid physical location including city, state, and rigs code. P.O. BOX NL3 BEPUS ARE NOT AMWA13111L Include nearest crass 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 forTYPE YPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIT)UAl., etc.) 4. - Check the appropriate box for TYPE OF BUSINESS. 5, If Facility/Site is Iocated within an Indian reservation or other Indian:: trust lairds, check the box marked YES' 6. Indicate the NL.iO4I3ER of TANKS at this SrI12, 7. Record'the Ta.P.i. it3 #, or ted , 3N'E in the; space provided. Il. PROPERTY OWNER `I ON & ADDRESS (MUST BE C O PI.St;1"ED) Complete all items in this section, unless all items are the sante as SEC CION 1; if the same, write "SAME AS SfIle* across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. M. TANK OWNER INFORMATION & ADDRESS (T US`I• IIIA C O PL, ED) Complete all items in this section, unless all items are the same as SE , . ON 1; If the sante, write 'SAME AS snl-" across this section. Be sure to check TANK 0V1bW--RS111P TWE box. . BOARD OF EQUALIZA71ON UST 9MRAGE I'M AC;COU BER,%TT BE11.7110) Enter your Board of I'.qualization (BOF.) LIST 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 tilt $0.066 (6 mills) per gallon fee due on the number of gallons placed in your US[`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 BOEI 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 942379, Sacramento, CA 94279-000L v. PErBOLF-um usT EINANaAL RuspoNmnny ( u . BE, e D) Identify the method(s) used by the owner anal/or operator in meeting the Federal and State financial responsibility requirements. USI's owned by any Federal or State agency are exempt from this requirement. VL I14GNOTTFIC.ATICIN A Cil ADDRESS Check ONE, BOX for the address that will be used for BOTH LEGAL AND BILUNG NOTH71C AVITONS. APPLICANF MUST SIGN AND OATllirm FORM AS INDICATED. SrRUC 110N FOR _ :a LOCAL ACI The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board {9]6)73)-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 '17HE N, T' ' OF 711I? LOCAL AGENCY TI 'T` INSPECTS '111F PA�IT�?` TO IT AC OF E TNTFOR TIC)N. IIS APPLICK171ON SOT BEPROCESSED 1111711F. BOR ACCOUNr NUMBER IS NOT FII.I,ED IN. THE LOCAL AGIiNCY IS RESPONSIBLE FOR THE C O PLM ON Oil THE ALO ' L AGENCY USE ONLY' INFORMN11ON BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIAIED FO "B'(s) TO THE FOLLOWING ADDRESS. SrAIT. OF CALIFORNIA ";rATE WATER RESOURCES CONIROL BOARD Ce/C) S. a a DATA PROCESSING CENITR P.O. BOX 527 PARAMOUN17, CA 90723