COMPLIANCE INFO_1986-2000 - Laserfiche WebLink

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s_ a; ;. ro-. VIWAN INSTRUCTIONS FOR COMPLETING FORM "All GENERAL INSTRUCTIONS: SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS AND SECTIONS 25286,25287,AND 25289 OF CHAPTER 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT. 1. One FORI4"A"shall be completed for all NEW PERMIT CHANGES or any FACILITIWSITE INFORMATION CHANGES. 2. SUBMIT ONLY ONE(1)FORM"A"for a Facility/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 AGORCY UNDERGROUND TANK INSPECTOR. 4.`Picric type or print clearly all requested information. S. Use a hard point writing instrument,you are making 3 copies. 6. Tank owner must submit a facility plot plan to the local agency as part of the application showing the location of the USTs with respect to buildings and landmarks[Section 2711(a)(8),CCR]. 7. Tank owner must submit documentation showing compliance with stats financial responsibility requirements to the local agency as part of the application for petroleum USTs[Section 2711 (a)(11),CCR]. 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. FACILITY/SITE INFORMATION&ADDRESS(MUST 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 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 properlocation. 3. Check the appropriate box for TYPE OF BUSL\ESS 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,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. II. PROPERTY 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 SI'Z'E"across this section. Be sure to check PROPERTY OWNERSI IIP TYPE box. III.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 SITE"across this section. Be sure to check TANK OWNERS TYPL box. IV,BOARD OF EQUALIZATION USI'STORAGE FEE ACCOUNT NUMBER(-MUST BE COMPLETED.SEE ARTICLE 5,CIIAIrI'ER 6.75, DIVISION 20,CALIFORNIA HEALTH AND SAFFTY CODE.) Enter your Board of Equalization(BOL)UST'storage fee account number which is required beforeyour pennit application can he processed. Registration with the 130E will cnsurc that you will receive a quarterly storage fee return in reporting the SO.(X)6(6tnills)per-galliat fee biuc on the number of gallons placed in your USTs. the BOE will code persons exempt from enying the storage fee so returns will not be sent. 14ou do not have an account number with the BOL:or if you have any questions regarding the fee or exemptions,please call the BUi at 916-322-9669 or write to the BOE at the following address Board of Equalization,Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0001. V. PE'1ROLl UM UST FINANCIAL RESPONsiBiLITY(MUS-r BE COMPLETED FOR PETROLEUM UST's ONLY,SEE SF(.J IONS 2711 (a)(8) OF TITLE 23,CIIAPTL'R.16,CALIFORNIA CODE OF REGULATIONS.) Identify the method(s)used by the owner and/or operator,in meeting the Federal and Statg'financ al responsibility requir:tnC:nts.UST's o"11CA by any Federal or State agency as well as non-pciroleurn UST's are exempt from this requirement. VI.LEGAL NOTIFICATION AND BTI_I..IIyG ADDRESS Check ONE BOX for the aadress that will be used for I3O`ITT LEGAL AND BILLING NOTIFICATIONS. TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN AND I)AT'E TTI .-FOR-41 AS 1\DICA'l'iiD. (Sl1'F S1 C"l l0NS 27l 1 (a)(13)OF TITI.E.23 CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.] INSTRUCTION FOR THE LOCAL AGENCIES The county an jurisdiction numbers are predetermined and can be obtained by calling the State Board(916)227-4303. The facility number may be- assigned eassigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If tht local agency prefers the State Board to assign the facility number,please leave it blank. IT IS THE RESPONSIBILITY OF THE LOCAL AGENCY THAT INSPECTS THE FACILITY TO VERIFY THE ACCURACY OFTHE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED 1N. THELOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORI'v4ATION BOX AND FOR FORWARDING ONE:FORIT"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD RETAIN THE ORIGINALS AND FORWARDTHE YELLOW COPIES TO THE FOLLOWING ADDRESS.THE PINK COPY SHOULD BE RETAINED BY'I III TANK OWNER. STATE OF CALIFORNIA SPATE WATER RESOURCES CONTROL BOARD C/O S.W.E.E.P.S. DATA PROCESSING CENTER P.O.BOX 527 PARA41OUNT,CA 90723 193 R)RO11di1