COMPLIANCE INFO_1993-2002 - Laserfiche WebLink

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INS'MUCTIONS FOR COMPLETING FORM "A" GENERAL INS"IRUCTIONS: 1+ ,Ope FORM "A" shall be completed for all NEW PERMIT'S, PERMIT CHANGES or any FACILITY/SITI? ;, •, ;INFORMATION CHANGES. 4 2. SUBMTT ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at tl site. 3. This form should be completed by either the PERMIT APPIACANT or the LOCAL AGENCY UNDTlRGROUNI) TANK 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" Mark an (X) in the box next to the item that best describes the reason the form is being completed. I. FACII,TI'Y/S1TE INFORMATION&ADDRESS (MUVr BE COMPLETED) 1. Record name and address (physical location) 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 ACL`F.PI'ABL13. 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. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORA'T'ION, INDIVIDUAT., etc.) 4. Check the appropriate box for TYPE OF BUSINESS. 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YT?,S". 6. Indicate the NUMBER of TANKS at this SITE. 7. Record the E.P.A. ID # or write "NONE" in the space provided. II. PROPERTY OWNER INFORMATION&ADDRESS (MUS"I' BE COMPLETND) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write :SAME AS SHV" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. M. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLEE'F.D) Complete all items in this section, unless all items are the same as SECTION 1; If the same, write ",SAME AS SII'I''." across this section. Be sure to check TANK OWNERSHIP TYPE box. IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPIJUTD) Enter your Board of Equalization (BOE) US'T 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 return in reporting the $0.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The BOE 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 BOE or if you have any questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the I3OE at the following address: Board of Equalization, Environmental Fees Unit, P.Q. Box 942879, Sacramento, CA 94279-0001. V. PETROLEUM UST FINANCIAL RESPONSIBILITY (MUST BE COMPLErFED) 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. VI. LEGAL NOTIFICATION AND IILLLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NOTIRCAT10NS. APPLICANT MUST SIGN AND DATE TILE FORM AS INDICATED. INSTRUCTION FOR THE IOCAL 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 TILE RFSPONSLBIIXff OF'11113 LOCAL AGENCY THAT INSPECTS 171E FACILI'T'Y TO VERIFY 1IIE ACCURACY OF THE INFORMAIION. 117IS APPLICATION CANNOT III, PROCESSED IF'II1E BOT:ACCOUNT' NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF111E "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCIATED FORM "B"(s)TO THE FOLLOWING ADDRESS. STATE OF CALIFORNIA STATIN WATER RESOURCES CONTROL BOARD C/O S.W.ums. DATA PROCESSING CENTER P.-P, BOX 527 PARAMOUNT CA 90723 �i