COMPLIANCE INFO_1996-2006 - Laserfiche WebLink

Home Browse Search

. . w7, _ . y INSTRUC ITONS FOR COMPLETING FORM "A" GENERAL,INSTRUCTIONS: 1. One FORM "A" shall be completed for all NEW PERMITS; PERMIT CHANGFS or any FACII.rTY/SPIT? 3NFORMAIION CHANGES. 2. SUBMIT ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at 111c ske This form should be completed by either the PERMIT APPI.1 Aivr or the LOCAL,AGENCY UNIWRt;RUIJND "TAMC INSPECTOR. 4. Please type or print clearly all requested .iniormation. 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 li^.st describes the reason the form is being completed. L FACIIXIY/STCF.INFORMATION&ADDRESS (MUST BE COMPI_E"TFff)) L Record name and address (physical locatiot.) of the undergr:auntl. t.ank(s). NO'IE: Address MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARI:?`NOT ACCwI'AB1.li 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 "SAMI:' in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. C:ORPORA'110N, 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, 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. 11. PROPERTY OWNER INFORMATION &ADDRESS (MUST BE COMPLL+rED) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write: "SAME AS SI'ITi" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. 'TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETE)) Complete all items in this section, unless all items are the same as SECTION 1; If. the same, write "SAMI?AS SPIT" across this section. Be sure to check TANK OWNERSHIP TYPE box. IV. BOARD OF EQUALMATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMPIi?". Enter your Board of Equalization (BOF.) UST storage fee account number which is,require'd 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 BOE at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PEI'ROLEUM UST FINANCIAL RESPONSIBILITY (MUST BE COMPLETND) 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 BIII.IIQG 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 RESPONSIBILITY OF THE LOCAL AGENCYTHAT HAT INSPECTS THE FACILITY TO VERIFY'11IF, ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNI' NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE,FOR TILE.COMP.ETION.OF T'HI:? *LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCIATED FORM "13'(s)TO TILE FOLLOWING ADDRESS. STATE.OF CALIFORNIA 1`, SPATE WATER RESOURCES CONTROL'BOARD C/O SW.LFI.P—& DATA PROCESSING CIiNII R P.O. BOX 527 PARAMOUNT,L-Ar%723