COMPLIANCE INFO_1986-1997 - Laserfiche WebLink

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INSTROONS FOR COMPLETING d*M "All 4� GENERAL INSTRUCTIONS: SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,21197,AND 25289 OF CHAPTER 6.7,DIVISION 20,CALIFORNIA IIEALTlI AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT. 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACILITY/SITE INFORMATION CHANGES. 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/Site,regardless of the number of tanks located at the site. 3. This form should be corripleted by either the PERMIT APPLICANT or the LOCAL AGENCY UNDERGROUND TANK INSPECTOR 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument,you are making 3 copies. 6. Tank owner must submit a facility plot plan to the local agency as part of the application showing the location of the'USTa with respect to buildings and landmarks[Section 2711 (a)(8),CCR]. 7. Tank owner must submit documentation showing compliance with state financial responsibility requirements to the local agency as part of the application for petroleum USTs[Section 2711(a)(11),CCR]. TOP OF FORM:"MARK ONLY ONE ITEM" Mark an(X)in the box next to the item that best describes the reason the form is being completed. L FACILITY/SITE INFORMATION&ADDRESS(MUST BE COMPLETED) I. 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 NUMBERS ARE NOT ACCEPTABLE. 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 0A ERSHIP(ex.CORPORATION,INDIVIDUAL,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 H or write"NONE"in the space provided. II. PROPERTY OWNER LNFORMATTON&ADDRESS(MUST BE COMPLETED) Complete all items in this section,unless all items are the same as SECTION 1;If the same,write"SAME AS SITE"across this section. Be sure to check PROPERTY OWNERSIIIP TYPE:box. III.TANK OWNER INFORMATION&ADDRESS(MUST BE COMPLETED) Complete all items in this section,unless all items are the same as SECTION 1:If the same,.write"SAME AS SITE.,,across this section. Be sure to chcc,k TANK OW NEIL S I YIIE box. I.V.BOARD OF LQUAL.ILATION LST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPLETED.SEE ARTICLE 5,CHAPTER 6.75, DIVISION 20,CALIFORNIA I11 ALTII AND SAFETY CODE.) Enter your Board of Equalization(1301:)UST storage fee account munber which.is required before your permit application can be processed, Rejstrati xa with the 130E;will cnsorc that you will receive a quarterly storage fee return in repotting the$0.006(6niills)per gallon fee due on the _ rnarnber of gallons placed in your USTs. 'Ilio BOL;will code persons exempt from paying the storage fee so returns will not be sent. Ifyou do not have an account nurnbcr with Clic BOE:or if you have any questions regarding the fee of exemptions,Please call the BOl at 9111-322-9660 or write to the BOL'at dmc following address Board of Equalization,Fuel Taxes Division,P.O.Box 912379,Sacramento,CA 94279-00tH. V. PETROL EUA•1 US l'FINANCIAL.RESPONS113ILITY(NIUST BE COMPLETED FOR PE"I ROLEUM US-I's ONLY,SEE SECIlONS 2711(a)(S) 0F'll'11_E 23,CIIAPI'1;R 16,CAI.II OR\IA CODE OF RL:(.il.11,.A'IIONS.) Identify the method(s)used by the owner and/or operator,in musing the Federal and State financial responsibility requirements.LISTS owticd by any Federal or State agency as well as non-p etrolcurn USTs are exempt from this requirement. VI.LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIFICATIONS. TANK OWNE.'R OR AU' 11ORIZED REPRESENTATIVE MI ST SIGN AND DATE:TILE FORAM AS INDICATED. [SEE SECTIONS 2711 (a)(13)OF TITLE 23 CHAPTER 16,CALIFORNIA CODE O.r REGULATIONS.] INS'I'RUCIION FOR TIIE LOCAL AGfiNCIES The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number may be assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the local agency prefers the State Board to assign the facility number,please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIVY'TIIE ACCURACY OF THE INFORMATION. TI LIS APPIJCATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. TIDE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY"INFORMATION BOX.AND FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD RI::TAIti"ITIS ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE i RETAINL•'D BY TLIE:TANK OWNER. i l STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O S.W.E.E.P.S. DATA PROCESSING CENTER d P.O.BOX 527 PARAMOUNT,CA 90723 3193 FM20111 Y