COMPLIANCE INFO_1992-2005 - Laserfiche WebLink

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0 0 INSTRUCTIONS FOR COMPLETING FORM "Art GENERAL INSTRUCTIONS: SECTION 2711 OF TITLE, 23, CHAPTER 16, CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25Z86,25287. AND 25289 OF CHAPTER . 6.7, DIVISION 20, CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMlT. 1. One FORM "A" shall be completed for all N EW PERMIT CHANGES or any FAC ILM/SITE INFORMATION CHANGES. 2. SUBMIT 6M.Y ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at the site. 3. This form should be completed 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"wing the location of the USTs 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 de"ibes the reason the form is being completed I. FACILITY/SITE LNFORIMATION & ADDRESS (MUST BE COMPLETED) 1. Record name and address (physical legation) 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 numbermust 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. 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 tnist lands, check the box marked "YES". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the F.P.A. ID # or write "\ONE" in the space provided. 11. PROPERTY OW NI RR INFORtiIA"17ON & Al)::)ItESS (�4t;ST BE COMPLETED) Complete all items in this section, unless all items are the same as SECIION 1. If the same, write "SAME AS SITE" across this section. Be sure to check PROPERTY OWNERSHIP TYPIC tx)x. I1L TANK OWNER INFORMATION & ADDRESS (NIUS"T' BE COMPLETED) Complete all items in this section, unless all items are the same as SECITON 1; If the same, write "SAME AS SITE" across this section. Be sure to check TANK OWNERS TYPL: box. IV. BOARD OF EQUALIl.ATION USI' STORAGE FEE ACCOUNT NUMBER (MUST BE CONIPLETED. SEE ARTICLE 5, CIIAPTFR 6.75, DIVISION 20, CALIFORNIA HEALTH AND SAFETY CODE.) Enter your Board of Liquali"ticn (110E) UST storage fee account number which is required before your permit applic:uion can be processed. Registration with the BOE will cncurc that you will receive a quarterly storage fee return in reporting the SO.(x)6 (6nulls) per gallon fee due can due number of gallons placed in your USTs. I lie 130E will code persons exempt from paying the storage fee so returns will not be soa. If you do nc.4 have. an account number with the B01or if you have any questions regarding the fee or exemptions, please call the B01 -at 91x1 -3'r2-9669 or write to the 1.3 OE' at the following addr:ss IIoard of Equalization, Fuel Taxes Div is ion, 11.0, Box 942x79, Sacramento, CA 91279.OoOL. V. PEIROL.EUM UST FINANCIAL RCSPONS 1-111, TY (1lUST BE CO-1PLIi'FED FOR Ill FROLEUM USTs ONLY, SEE'SECTIONS TIONS 2711 (a)(S) OF ITILF. 23, CI IAPTL'R 16, CALIFORNIA CODE. OF REGULATIONS.) Identify the ntcthW(s) used by the owner andfor operator, in meeting the Federal and State financial responsibility irquirculcrds. LSTs ov Mid by any Fedcr;il or State agency as well as non-pctrolcurn USTs are exempt from this requirement. VI. LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE' BOX for the address that will be used for MOTH LEGAL AND BILLLYG NOTIFICATIONS. TANK OWNER OR AUT11OR.Il...ED REIIRF.SENTATIVE MUST SIGN AND DATE THE FORM AS INDICATED. [SEF. SECTIONS 2711 (a)(13) OF'TI"I'I..F. 23 C1IAlyfER 16, CALIFORNIA CODE OF REGULATIONS.] INSTRUCTION FOR THE LOCAL ACiENC1FS The county an jurisdiction numbers are predetermined and can be obtained by calling the State board (916) 227-4303. "Fhe lactlity 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 TIII.' RI.SI'ONSIBll.lTY OF TILE LOCAL AGENCY THAT INSPECTS TILE FACILITY TO VERIFY THE ACCURACY OF TFIE LNFORMATION. TIIIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER 3S NOT FILLED IN. TIIF. LOC:AI, AGENCY IS RI SPONSIT3LF; IL FOR THE COMPLFTION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND ASSOCIATED FORM "B"(s) TO THE FOLLOWING ADDRESS. TILE LOCAL AGENCY SHOULD RETAIN TIII: ORIGD ALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING ADDRESS. TILE PINK COPY SHOULD BE RETAINED[31' "KITE TANK OWNER, STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O_S.W.E.E,P.S. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723 3'93, RA12DRI