COMPLIANCE INFO_1985-1993 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM "A" GENERAL.,INSTRUCTIONS: 1. One FORM "A" shall be completed for all NEW PERWIS, PERMIT CIIANGIES or any FACILrl'Y/srl'Ii INFORMATION CHANGES. 2. SUBMIT ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at the ,ire. 3. Tliis form should be completed by either the PERMIT APPI.JCAN.T or the LOCAL.AGENCY UNDI?RCiROUND TANK INSPWI'OR. 4. Please type or print clearly all requested information. S. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM: "MARK ONLY ONE ITEM" 'Aa k. an (X) in the box nett to the item that best describes the reason the forst is l.ving completed. 1. FACIL r Y/scl7,INFORMATION&ADDRESS(MUST BE COMPI"TED) 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 ACC ErTABL E. 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, 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. H PROPERTY OWNER INFORMATION&ADDRESS(MUST BE C OMPI131M) Complete all items in this section, unless all items are the same as SECTION 1; if the same,write ".SAME AS SII7i" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. 11H. 'LANK OWNER INFORMATION&ADDRESS (MUST BE COMPL.,ETED) Complete all items in this section, unless all items are the same as SECTION 1; If the sante, write�"SAME AS Srn-" across this section. Be sure to check TANK OWNF-RSIILP TYPE box. IV. BOARD OF EQUALIZATION UST STORAGE FIS.?ACCOUNT NUMBER(MUST BE COMPIE'113)) 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 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. PETROLEUM UST FINANCIAL RESPONSIBILITY (MUST BE COMPIZIFD) 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. L.EGAL.,NO`IMCATION AND 11I1"NIG,ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL.AND BILLING NOTIFICATIONS. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSI'RUC TION MR 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 RES1110flWMILITY OF THIS LOCAL AGENCY THAT INSPECTS THE FACH II"Y TO VERIFY THE ACCURACY OF THE INFORMATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IN. 173E LOCAL AGENCY IS RESPONSIBLE FOR TIBE,COMPLETION OF TME "LOCAL AGENCY USE ONLY" INFO 'ETON BOX AND FOR FORWARDING ONE FORM "A"AND ASSOC[AIM FORM -W(s)TO THE FOLLOWING G ADDRESS. STATE OF CALIFORNIA STATE WATER RESOURCES CUNTROL BOARD C/O &W"-m DATA PROCESSING CEMER P.O. BOX 527 PARAMOUNT, CA 90723