COMPLIANCE INFO_1986-2004 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "A! GENERAL INSIRUCIIONS- L One FORM "A" shall be completed for all NEW PERMITS, PERMIT CHANGES or any FACILn"Y/sriv. INFORMATION CHANGES. 1 2. SUBMIT ONLY ONE (1) FORM "A! for a Fagility/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 UNDER(MOUND TANK INSPECTOR. 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copi=-s. 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 FACUMT/SIM INFORMATION & ADDRESS (MUST BE COMPLETED) 1. Record name and address (physical Ideation) of the underground tank(s). NOTE: Address MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARB 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. Clieck the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INDIVIDUAL, etc.) 4. Check the appropriate box for TYPE OF BUSINESS. S. 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 # or write "NONE" in the space provided. H PROPERTY OWNER ]INFORMATION & ADDRESS (MUST BE COMPLLMM) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write 'SAME AS SITI? across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. Ill 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 srI`E across this section. Be sure to check TANK OWNERS)[11P TYPE box. IV BOARD OF EQUALIZATION UST STORAGE. FEE- ACCOUNT NUMBER (MUST BE compur.nED) Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application can be processed. Registration with the DOE will ensure that you will receive a quarterly storage fee return in reporting the $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The DOE will code persons exempt from paying the storage fee so returns will not be sent. If you do not have an account number with the DOE or if you have any questions regarding the fee or exemptions, please call the DOE at 916-323-9555 or write to the DOE at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PETROLEUM UST FINANCIAL RESPONSIBIL]ITY (MUST BE COMPLETED) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. USTs owned by any Federal or State agency are exempt from this requirement. VL LEGAL NOTIFICATION AND BUJING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND B&LING NOTIFICATIONS. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRUCTION FOR THE LOCAL AGENCIES 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 and cannot contain any alphabetical. If the local agency prefers the State Board to assign the facility number, please leave it blank. IT IS THE RESPONSIBIJI-nT OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERWY 1111F ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF'17W, BOE ACCOUNT NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE FOR TIM COMPLETION OF *11IR TOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "V AND ASSOCIATED FORM '13'(s) TO 171B FOLLOWING ADDRESS. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O &WEJ Lips, DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT, CA 90723 0 91