COMPLIANCE INFO_1996-2002 - Laserfiche WebLink

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fN,STWJC110NS COMPLETIN6 W GENERAL 4"' 1, H be couplet J for all NIV PFRMI'VS, IT"11mr1, 01ANGE-S at;„; FACIVITY/SITE (71ANGF& 2. SUBM o),* IfNAM owi for a FacilityiSne. regardless of the nunnher orf tanks locwd z!l d %J c, 3. 'Ibis fo� the Pt f APPLICAMI'or the LOCAL AGENCY UNDUR6ROUND TANK '�J\ 4, Pleasc, lyl,,- print c1carly all requested information. 5. Use a hard point writing instiument, you are making 3 topics. TOP OF FORM:- "MARK ONLY ONE ITEM” Mark an (X) in the box'ncxt to the item that trent describe, the reason the form is being completed. 1. FAC7ILrI-Y/Srf`E fM4)RNV,,'11ON &ADDRESS (MUST IfE,COMPLE310) 1. Record tranic 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 N(YI.'AC(371ADFR 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 "SANIF" in proper locaii*1 3. Check the appropriate box for TYPE OF BUSINESS OWNERSItIP (ex. CORPORATION, INDIVII)JAIT'qc.) 4. Check the appropriate box for TYPE OF BUSINESS. 5, If Facility/Site is located within an_Indian reservation or other Indian trust lands, chuk the-bow marked-'YES". 6. Indicate the NUMBER of TANKS at this SI'I'E. 7, Record the E.P.A. ID # or write "NONE" in the space provided. 11. 1YROPERTY OWNFR S (MUST BE COMPIZIED) Complete all items in this section, unless all items are the same as$14K.TION 1; if the same, write "SAME-AS SI`W" acrOss this section. Be sure to check PROPFKIY OWNERSHIP TYPE box. HL TANK OWNER INFORMAIION & ADDRESS (MUST BE COMPLITIED) Complete all items in this section, unless all items are the same as SECTION 1: If t I he same, write "SAME AS SH17" across this section. Be sure to check TANK-OWNERS111P TYPE,box. IV. BOAR13 Of'EQUALL/AlION UST SIX)RAGE,ITT.ACCOUNT NUMB13R(Wisr BE COMPLETED) Enter your Board of Equalization (BORD U51' 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 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 1301-7 or if you have any questions regarding the fee or exemptions, please call the BOLI at 916-323-9555 or write to tl(e BOE at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PFI'ROLEUM UST FINANCIAL RESPONSIBUXIT (MUST BE COMPLITIT4,13) I i 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 arc exempt from this requirement. VI. LEGAL NOTIFICATION AN13 RUJING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILLINCY NOIIFI(W1IONS. APPLICANT MUSI'SIGN AND DATE THE FORM AS MICNIVI"I IN,%IkUCIION FOR TIIE LOCAL AGENCIES The county and jurisdiction=mbers are predetermined and can be obtained by calling the State Board (9'16)739-2421. The facility number may be assigned by the local agency-, however, this number must be numerical and cannot contain any alphaf)etical. If the local agency prefers the State Board to assign the facility number, please leave it blank. YF IS THE RINPOINSIBI]XI'Y 01711113,LOCAL AGEWY '11TAT SPE C. '111F FACILr1'Y'1`O VERIFY TTIE S 'D ACCURAC`Y 0F'IIIE INFORMN.110N. IIDS APPLICAIION' "ANNHY1' BUI PROCEME IF`17IE DOE ACCOUNT NUMBER IS N(.Yl'FII-LED IM TILE LOCAL AGENCY JS RFSO tNSIRH,-� FOR 1111i COMPLEITON OF ITIE, "LOCAL.AGENCY USE ONLY" INFORMATION BOX ANI) 1i1 0< FORWARDING ONE FORM "A"AND ASSOCIATED FORM W(s)TO TELE FOLLOWING ADDRUSi STATE OF(:AI.U?ORNIA SPATE WAVER RESOURCES CONTROL BOARD C/o &W"-m tPNI'N PROCESSING CENTER P.O. BOX S27 PARAMOUNT, CA (X)723 A