COMPLIANCE INFO_1985-2006 - Laserfiche WebLink

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C1 - J!, +ab ffi, ..� INS.TRU('TIONS TY)R COMPLE 17ING FORM "A" GENERAL IN`;1'12t1£f1ONS. 1. One FORM "A" shall be completed for all NEW PERMr.lS, PI',RMTT CIIANGI S or any FAC:I TIN/SITE, INFORMI41ION CHANGES. 2. SUT:MI'F ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at the site. 1 This form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDUR6RO .1N17 f TANK INSPECTOR 4. Please type or print clearly all requested information. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM: "MARK ONLY ONE fI`FM" :~dark an (X) in the box next to the itetn�that best describes the reasTif the,:form is:lletin�;tostr�aleted. - - 'rt L FACII.rI'Y/Sr11: INFORMATION & ADDR (j1aUST BE C'OMPLE11a)) 1. Record name and address (physical location) of the underground tank(s), NOTE: Address MUST have a valid physical location :ncluding city, state, and zip code. s P.O. BOX NUMBERS ARE NCYr ACC:EPrAni ?. 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 location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORA'TiON, INDIVIDUAL, etc.) 4. Check the appropriate laox 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. Il) # or write "NONE" in the space provided. H. PROPER'T'Y OWNER INFORMATION &ADDRESS (MUST'BE COMPLFItiD) Complete all items in this section, unless all items arc the same as SECTION 1. if the same, write *SAME,AS SrIT.* :across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. TANK OWNE1 TNFORMA:IION &ADDRESS (MUST BE COMPIVID) Complete all items Iii i:this section, unless all items are the same as SEM- ON t:1;1 Ithe 3atit 'fvYite"SAME AS 41,11. brows this section. Be sure to check TANK OWNERSHIP TYPE box. IV. BOARD OF EOUAI17ATION UST S ORAGE FEE ACCOUNT NUMBER(MUST BE co .1a°im) Enter your 136at•d of Equalization (BOE) US'T storage fee account number which is required before your permit applihaiiioin 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 UST'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 B0Z? or if you have any questions regarding the fee or exemptions, please call the BOL:at 91.6-323-9555 or write to the BOF ,It the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PETROLEUM UST FINANCIAL RESPoNsiBIL1Ty (MUST BE COMPIFmm) 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 LEGAI,NOTIFICATION AND BII.I.ING ADDRESS Check ONE.BOX for the address that will be used for BOTH I..FXiAI..AND BII.IING NO11FICA11ONS. APPLicANT MUST NIGN AND DATE TIIE FORM AS INDICATED. INSTRUCTION FOR 17HE LOCAL AGENCIPS 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 abency, 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. rT flspm RIiSPONSIBI OF 1111-LOCM,AGINC'Y THAT INSPECI;S`THE FAcu ri y'TO vmu y 711E ACCURACY OF THE INFORMATION. THIS APPLICATION CANN(Xr BE PROCESSED IF 111E BOE AC COUNT' NUMBER IS Nffl* FTLLFD IN. 11IE LOCAL AGENCY IS RP—%TONSIBLE FOR 11113 COMPLETION OF 111 'LOCAL AGENCY USE ONLY* INFORMATION BOX AND FOR FORWARDING ONE:FORW"A" AND ASSOC:IA`1Td3 FORM 'B'(s)7'C) 'THE FOLLOWING ADDRESS. STAIE OF CAI IFORNIA STA71? WATER RESOURCES CONTROL LARD C/O S.W.IL ISS. DATA PROCII&SING CENTER P.O. BOX 527 PARAMOUNT, CA 90723 K_