COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

Home Browse Search

INSTRUCTIONS FOR COMPI.I LING FORM"A' GENERAL 1N9TRUCIIONS. 1. One DORM `,A"shall be completed for all NEW PERMITS,PBRMrI'CHANGES or any FACIL1'T"Y/srim INFORMATION CIIANGES. 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 completed by either the Pf"IRMIT A1'1'11("ANI'or the I.C.)(.AL AGENCY UNDERGROUND TANK IN'cT EC71'OR. 4, Please type or print clearly all requested information. 5. Use a hard point-writing instrument,you are making 3 copies. TOP OF FORM: "MARK ONLY ONE TIIiM" J. Mark an (X)in the box next to the item that best describes the reason the form is being completed. I. FACIIXrY/SrII3 IM70RMNIION&ADDRE&S(MUS`r BE(YJMPI.I?111)) 1. Record name and address(physical location)of the underground tank(s). ;"SIO'111,': Address MU,1w I'have a valid physical location including city,state,and zip axle. P.O. I30X WiMBER ARE NOT AC'CIXI-ABITL Include nearest cress street and name of the operator, L Phone number must have an area code. If the nig=ht number is the same,write "SANIUU"in proper location. 3. Check the appropriate box for TYPE OF BUSI,NFSS OWNI RSLIIP (ex. C;ORFORXIION,INDIVIDUAL,,etc.) 4. Check the appropriate box for TYPE OF BUSINL;SS. 5, If Facility/Site is located on land within an iridian reservation or other indian trust lands,check the box marked "YES", 6. Indicate the LUh-BL R o€`L'ANKS at this SI'1`I?. 7. Record the E.P.A. IT)# or write"NONE" in the space provided, 11. PROPERTY OWNER INFORMATION&AI)IIRF:SS(MtJsr BE COMPI..I,no) 1. 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 PROPERTY OWNERSlIIP TYPLi box. III.TANK OWNER INFORMA71ION&ADDRE S(Mtlf"4F"BE COMPI14,1141)) 1. Complete all items in!his section, unless all items are the sante as SE "PION 1; If the same,write"SAME AS S 17 " across this section. Be sure to check TANK OWNERSHIP T'YPF?box, IV BOARD OF UMALMNLION U91'Ssix 2A(il3 FEE A(;('i3UN 'NUMBER(MUST BE C()MI'I.1rl'IM) U iter your Board of Equalization (130f',*) USI"steerage fee account number which is required before your pernait application can be processed. (Registration with the BOE will ensure that you will receive a quarterly storage fee return in reporting the$0.006 (G mills)per gallon fee due-on the number of gallons placed in your L STs. The ROE will code persons exempt from paying the storage fee so returns will not be sett. If you do not have an account number with the 13OF or if you have any questions regarding the fee or exemptions,please call the 130E at 916-739-2582 or write to the DOE at the following address: Board of F.guabzation, Env9ronmcntal fees Unit,P.O. Box 942879, Sacramento; CA 94279-0001, V. LEGAL NO IFI(W11ON AND 131I.I.INCi ADDR01;:S 1. Check ONE BOX for the address that will be used for B(YI'11 LEGA(,.AND BILLING NO11FI(WITONS_ A:PPI.FCAN'I'MUST SIGN AND DXII:i'FII:(:FORM AS INDXWI[17D. E,'A'RUCT'ION R)R 1116 IAX AL A(;FNCWS 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 anis cannot contain an alphabet. If the local agency prefers the State Berard to assign the facility number,please leave it blank. rr IS 11111 R1:SPONSI13UTIN OF TTIE LOCAL AGENCY'I1IA7I'INSPF3C'1'S'I1IE ItA(MXI'Y TO VERIFY TIM ACC`URAC-Y OF TRIS 1NFOPMXIION. 'III.IS APPI,1(:NIION('ANN(7I'I3Ii PROCt3SSliD I1r'1IIE 13 )i?A(C()twr NUMBER IS N(Yr F11,11-0 IN. '1111:LOCAL AGI N("Y IS RRSPONSIMJi ICOR TI IE(X)MPI.E'I1ON OF111E'LOCAL AGENCY USE ONLY'INFORMATION 13OX ANT)FOR FORWARDING ONE FORM"A'AND ASSOCIAT'I31)FORM 'B'(s)T.IY`III(?;I10I.1,0WING,ADDRI?S& SIXII.1 OF CALIFORNIA STNV!WA7171R RFSOURCII-S CONFIROL BOARD c/o s.WJ 1?.P.S. DATA PROCESSING CEN-J ER P.O.FOX 527 PARAMOUNT,CA W722-3