COMPLIANCE INFO_1986-1993 - Laserfiche WebLink

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INS17RUCIIONS FOR COMP ..I 11NG FORM "A' GENERAL INS17RUCITONS. 1. One FORM "A" sha;l be completed for all NNR`.,VPERMrn, PI.'RM17I` FIA 'G S or any FAC'Il.MY/SF1,1; 1NI?01MX1ION CHANGES. 2, SUBMrr ONLY ONE (1)'FORM "A" for a. Facility/Sitc, r(gardlcais of the number of tanks located at thy. nate. 3 17his form should be completed by either the PERMIT PF' IC. ",f,T °car the LOCAL AGE? C Y L;1VI7IR(;R0lJND 'I"ANiaa INSTI?( FOIL 4. Please type or print clearly all requested itnormation. 5. Use a hard point writing instrument ou are making 3 copi, s. TOP 017 FORM. r "MARK ONLY ONE M" Mark an (X) in the box next to the item that °atst describes the rea.,n_,n the form is being completed. 1. Record name and address (physical location,,) of the undergioun°; :ank(s). NOTE: Address MUST have a valid physical location including f.ity, state, and zip code. PO. BOX NUMBERS ARE, NOT ACCE717ABIlL Include nearest crass street' and name of the operator. 2. Phone number must have an area cede. If the night number is the same, write SAME" in proper location, 3. Check the appropriate box forTYPE OF BUSINESS C4WNERSHIP (ex. CORPC9RAI'ION, INDIVIDUAI.,, 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. H. PROPERrY PROPEROWNER 04FORMA110N & ADDRESS(MUST' BE CC)MP rI-ED) Complete all items in this section, sonless all items are the same as SECTION 1; if the sante, write " ° MF; AS Sr E" Gacros's this section. Be sure to check PROPERTY OWNERSHIP TYPE box. TANK OWNER`INFORMATION & ADDRESS (MUST BE C) PLHII?I)) Complete all items in this section, unless all items are the sante as SECTION 1; If the same, unite "'SAME, AS S1"1'E' across this section. Be sure to check TANK 0VMEJM1IP IWE box. IV. BOARD OF EQUALIZATION UST S17ORAIGE, FIX -ACCOUNT NUMBER CISr BE C, LE11A ) Enter your hoard of Equalization (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 Pee due on the number of gallons placed in your USTs. The BO will code persons excmpt 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 BOE at 916-323-9555 orwriteto the BOE at the following address: Board of I-RIualization, Environmental Fees Unit, P.O. Box 942579, Sacramento, CA 94279-0001. V. PETROLEUM UW FINANCIAL RE SKIT.,(MUST E CC) T.T:, T)) Identify the method(s) used by the owner and/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 LEGAL NOTIF[CATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND IIHIING NC711FI "T°[ s, PTHC. I° MUST SIGN AND DATE 7111131 FORM AS INDICATED. INSTRUCMON FOR THE LOCAL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (976)739-242]. "I°lte 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 hoard to assign the facility number, please leave it bitmk. IT IS THE OF MIE LOCAL AGENCY TIIA'I INSPBM HE FACIIM TO VERIFY TIIF ACCURACY OF ITIE INFORMATION.PPLI0VI 1ON CANNOT BE PROCESSED IF 11W, DOE ACCOUNF NUMBER IS NOT FILLED IN. THE- LOCAL AG13NCYIS RESPONSIBLE FOR 1111E COMPLETION Of' It. "LOCAL AGENCY USE: ONLY" INFORMAMON BOX AND FOR IX)RWARDING ONE FORM "A'.AND .i SSC3 °1111) I -IP(s) TO 14E FOLLOWING ADDRESS. STATE OF CAIIFORNIA STATE WATER RESOURCES CONTROL BOARD C/a.- s ' . P.O. BOX 527 PARAMOUNT, CA %723