COMPLIANCE INFO_1985-2000 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPI UnNG FORM "A" GENERAL INSTRUCTIONS: FORM "A" shall be completed for all NEW PERMITS, PERMIT C IIANGEN or any FACILITY/SI17i O R,14 11ON CHANGES. 2. SUBMIT ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at the sitc- ? s r,�r- s}lcAd be completed by either the PERMIT APPLICANT or the LOCAL,AGENC Y UNDFRGROtJN D TANK INSPECTOR 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" \1jrk an (X) in the box next to the item that best describes the reason the form is being.completed. I. FACIIXI-Y/SITE INFORMATION&ADDRESS (MUST BE COMPLL'I'EID) L 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 ACCTT'1ABIZL 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. CORPORATION, INDIVIDUAL.,, 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, cheek the box marked "YE.S". 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 COM.PLLr1'ED) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write "SAME A.S SITE:" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. M. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPI.Emm). . Complete all items in this section, unless all items are the same as SECTION 1; If the same, write "SAME AS SITE" across this section. Be sure to check TANK OWNERSIRP TYPE box. IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(MUST III:? COMPId I10) Enter your Board of Equalization (BOE) UST storage fee account number which is required before your permit application can be processed. Registration with the BOE Mll 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 BOT? or if you have any questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOF., at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PETROLEUM UST FINANCIAL RESPONSIBILITY (MUST BE COMPLE'FED) 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 BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLING NO1114CATIONS. APPLICANI° 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 RFSPONSIBUXI'Y OF 111E LOCAL AGENCY THAT INSPECTS'11IE FACILITY TO VERIFY 711E ACCURACY OF 111E INFORMA110N. TIUS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNI° NUMBER 1S NOT FILLED IN. 'ITIS LOCAL AGLWCY IS RE.SPONSHILE.FOR TILE, COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A" AND AS.SOMI 11iD FORM "B"(s)TO 'I11E FOLLOWING ADDRESS. STAT OF CALIFORNIA S'IATE WRIER RESOURCES CONTROL BOARD c/o &WXU,—P S. DATA PROCESSSING C ENI ER P.O. BOX 527 PARAMOUNT, CA 90723