COMPLIANCE INFO_1997-1998 - Laserfiche WebLink

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IN,'3'1'RUC`t7ONS FOR C()MPIH11NG IRR;'�A' GENT Fs INS I'RUCnONS.- 1. One FORM"A"shall be completed for all NEW PERMITS,PERMIT'CHANGES or any FACIllry/sm! INFORMATION CHANGES. 2. SUBMIT ONLY ONE(1)FORM W 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 AGMCY UNIX.,"RGROUNDTANK INSPECTOR. 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 ITEM' 1. Mark an(X) in the box next to the item that best describes the reason the form is being completed. 1. lf?ACILT1 Y/SITE INFORMATION&ADDRESS(MUST BE CX)MPLI-Tia)) Record name and address(physical location)of the underground tank(s). I NOTE: Address MUST`have a,valid physical location including city,state,and zip code. Ta.BOX NUMBER ARE NOT ACCEVrABLK 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 lo,alon. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP(ex. CORPORATION, INDIVIDUAL,c1c) 4. Check the appropriate box forTYPE OF BUSINESS. 5. If Facility/Site is located on land 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# or write'N; ,ONE" in the space provided. H. PROPERTY OWNER INFORMATION&ADDRERS(MUST BE COMPITN'0)) 1. - Complete all items imtjhs-sect}cm, unless all items are the same as SECTION 1:-if the same,write 6SAMI.TASSrj'jj*across, this section. Be sure to check PROfltlrl-Y 6WNERSHIPTYPE box. IIF."TA OWNER INFORMATION&ADDRE&S(MU',';I'BB coMPrv-1130) 1. Complete all items in this section, unless all items are the same as SECTION 1: If the same,write "SAME AS SlTli" across this section. Be sure to check TANK OWNTWITIPTYPE box, IV WARD OF HQUALFZ.K11ON US17,q'ORACII?IME AC'0OUNT NUM[H.,R,(MUSI'BH COMPLI11.0) Enter your Board of Equalization (130F') USI'storage fee account nuniber-which is required before your permit application can be processed. Registration with the BOE will ensure that you will receive a quarterly Storage fee rettirn-in teporting the Sl 1W) (6 mil'Is)per gallon fee due on the number of gallons placed in your UFf's. The BOE-,vrill code persons exempt from paying the rag stofee so returns will not be sent. If you do riot have an account number with the 130f,"or if you have anvAuespi6n�- storage regarding the fee or exemptions,please call the BOF at 916-739-2582 or write to the BOE"at the following address: K)ard of Equalization,Environmental Fees Unit, P.O. Box 942879,Sacramento, CA 94279-0001. V, LEXIAL NC331FICN1`ION AND BILLING ADDRIT-S-1; 1. Check ONE BOX for the address that will be used for BOTITTI MAL ANI:i B1111*7 N(Y11FWATION& APPLK_'AMP MUS' SKIN AND DATE TIIE FORM AS INDICATED. IN911'RUCITON FORTIW,WCAL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)73(1-2121. 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 TIIE RE-SPONSIBIL171-Y 017111E LOCAL AGENCY TIIAT INSPEC71N, 11111 FACIIXITTO VERIFY TIIE ACCURACY OF 11112 INFORMATION. WIS APP11CMI70N CANNOT BE PRocEssip IF 711113 BOF ACCX,)UNT NUMBER.IS WYF FILIXl)IN. TIIE If)CAL AGINCY IS RE SPONSIBI-E FOR 111E C()MPI_JU1ON OF TIIE*LOCAL AGENCY USIi ONLY"INFORMA'110N BOX AND FOR FORWARDING ONE Iq)RM W AND ASSOCIA711M FORM *B'(s)TOTIIE FOLLOWING ADDROSS. STIVIE,OF CALIFORNIA SUATEi WATER RIW)UR(MS CONTROL BOARD C/O&W.R17-P.S. DIVI'A PRM_ISSING CINIER, P.O.BOX 527 PARAMOUNT,CA 9VM