COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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TRUC".I1ONS FOR C.OMPLUI "A' 1NS 7CII?NF L INSTRUCnONS: L One FORM"A"shall be completed for all NEW PL'RMTI'S,PERMIT'01ANGIN or any FAC I1JYY/ST1E INFORMATION CHANGES. 2SUBMIT ONLY ONFi(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 APPIdCANT or the LOCAL AGENCY UNI-N.I.RGROUM3 TANK. INSPFA—I'OR. 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument,you are making 3 copies. TOP OFYORM: "MARK ONLY ONE rIMM" Mar an()C) in the box next tcs the item that best describes the reason the form is being completed. I. FAC H WFORMA"TIO14,r A `Vis C OMPLITII" 31 '` 1.7�R cord name and address(physical location)oT'che underground tank(s). y NOTE: Address MUST have a valid physical location including city,state,and zip code. P.O:BOX NumBF,*ARI?.-N>T AC:CEPTABia Include nearest cross street and name of the operator. 2. Phone number must have an arca code. If the night number is the same,write"SAMIs"in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex. CORPORt1TION, INDIVIDUAL,etc.) 4. Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Site is locatcic cm land within an indian reservation or other indian trust lands,check the box marked "YIDS". 6, Indicate the NUMBER of TANKS at this STT-. 7. Record the E.P.A. 11) #or write"NONE" in the space provided. H. PROPERTY OWNER INFORMKI ION&ADDRESS.(MUST BE COMPI.I:IDED) 1. Complete all items in this section,unless all items are the'salite a.5 S-C TIO" I if the same,write "SAME AS SITE'acv'c,s5 this section. Be sure to check PROPEW17Y OWNERSHIP'TYPE box. III.TA OWNIsIt.I:NI?O N[ION&ADDRF,—SS(MUST BP.COI4tA! "> lij., L Complete all items in this section, unless all items are the same as SI..C nON 1; If the same,write "SAME?AS SITE' across this section. Be sure to check".TAMC 0WN1!%T11PTYPE box. IV BOA OF Ia U A`IION US.I'91'O CaI?ll:rLT A(; UNI"NUMBER(Mp,';I"BF C,O II..EllaI)) Enter your Board of Equalization (BC)-) 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 retearn1n reporting the 9.006 (6 mills) rwr 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 scturns will riot be sent: If you des not'have an account number with the BOI: or if you have any questions regarding the fee or exemptions,please call the 1301., at 916-7,19-1582 or write ao the BOI3 at the following address: K-)ard of Equalization,Environmental Fees Unit,11.0. Box 9"12879,Sacramento, CA 94279-,W)L _ I13XIIAL N .'I1gCA'TION AND 1IIId..ING ADDRESS e Check ONE,BOX for the address that will be used for BOTI1 I.JiGAL AND 13111Is G NO11FICATIONS. AI'P o3'I'Poli:s;r SIGN AND T)ATU'IT CA'111.0. w r INS17RUC'ITON FOR.11M.JA-)CAL AG.HN(.1ris The county and,jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)739-2121. "The facility number may be assigned by the local agency, however,this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the facility number,please leave it blank, IT IS TIII? PONSIBU117Y C)F THE I..,C)C"AL AGENCY TTIAT INS'PDt`I:s"I i II?FAC II.I FY TO YI?RIFI!'t HE ACCURACY OF TIIt3 INFORMATION. THIS 'I'IJ(A 17ON C ANNCFT BL,PROC.:SSBI)IF'171E BOD ACkY,)UNT NOWWRISNOTHIJAIT)INe -111 i LOCAL AGI.?NCY IS RESPONSIBLE NS'IBLE FOR TIA's C:OMPLI?CION OF"'IIID"IACAL AGPINC Y USE ONLY"INFORMK1ION BOX AND FOR FORWARDING ONE FORM"A"AND ASSOCIA`I ED FORM , "B"(s)TO 111 1-1011.0WING ADDRESS . STKrE OF CALIFORNIA STA'I'D WAMR SOURC VS C ONFROL BOARD C/O s.W.I=1 P.S. DATA PRO CMSS C. ('1R P.O.BOX S27 PARAMOUNT,CA 900