COMPLIANCE INFO_1986-2007 - Laserfiche WebLink

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INSMUMIONS FOR compumNG MRM 'A" GIVE INSTRUMIONS: I- One FORM "A" shall be completed for all NEW PERMITS, PERMIT MANGES or any FACIll.rry/suE. INFO TION CIIANG1HS:. 2, SIMMIT ONLY ONE (1) FORM A"for a Facility/Site, regardless of the number of tanks located at dic site. 3, This form should be completed by either the PERMIT APPI.ICANT Or the AGENCY UNDERGIMUND TANK INSPECYOR. 4, I'lease type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. TOP OF MM- "MARK ONLY ONE n'Em" -Mark an (X) in the box next to the item that best describes the reason the form is being completed. I. FACILrI-Y/,SrI1-z INFORMATION & ADDRESS (MUST BE coMPLL"ITO) 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 NUMBEWS ARE NOT AM.iFTABLUL 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 locadon, 3. Check the appropriate box far 'TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION. IN1)IVlf,%AI,, cic,) 4. Check the appropriate box for TYPE OF BUSINESS, S. If Facility/Site is located within an Indian reservation or other Indian trust lands. check the box marked "Yf"^S?I. 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A. IT) # or write "NONE" in the space provided. H. PROPER'L'Y OWNER INFORMXI70N& ADDRESS (MUST BE COMPLUMD) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write "SAME.AS Srlli' across this section. Be sure to check PROPER'I'V OWNERSHIP TYPE box. M. TANK OWNER INFORMATION & ADDRESS (MUITI'BE COMPLUMD) Complete all items in this section, untess all items are the same as SEC'FION 1; If the same, write "SAME AS SrI'E" across this section, Be sure to check 'I'ANK OWNF.R,%I1P'[YPF box, IV. BOARD OF EQUALIZAMON UST STORAGE FFE ACCOUNT NUMBER(MUST BE (X)MPtjrMD) Enter your Board 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 lhe $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. 'The BOE will code persons exempt trona paying the storage fee so returns will not be sent. If you do not have an account number with the 130E or if you have any questions regarding the fee or cxcrnptions; please call the BOE at 916-323-955S or write to the BOE at the following address! Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PFI"ROIX.UM UST FINANCIAL RESPONSIBILITY (MUST BE COMPLE-IT13) 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 :vill be used for BOTI1 MiAL AND BH1JNG NOTIFICATIONS. APPLICANT MUST SIGN AND DNITi ITIE FORM AS INDICAJTD. INSTRUMON FOR'111F WCAL 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 alpflahetical. If the local agency prefers the State Board to assign the facility number, please leave it blank. 171'IS TIM, RESPONSIBHXff OF TIM LOCAL AGENCY THAT INSPECIN'114E FACILITY '.I'O,VE-R1[I1Y'111B ACCURACN OF ITIE INFORMATION. TIMS APPLICATION CANNOT BE PROCESSED IF THE BOE ACC 6UMI' NUMBER IS NOT FILLET} IN. 11111- LOCAL AGFNCY IS RF-SPONSIBI14,FOR'111E COMPLETION OF"IF, "LOCAL AGENCY USE ONLY" INMRMNITON BOX AND 17OR FORWARDING ONE FORM "A" AND ASSOCIATEI) FORM 'B'(s)TO THE FOLIO NG ADDRESS. STA1117 OF CALIFORNIA srAw WAITR RESOURCE-S CONI-ROT,BOARD C/o &W.r--E.P--- DATA PROCESSING CMNITR P.O. BOX 527 PARAMOUNI, CA 90723