COMPLIANCE INFO_1985-1998 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLETING FORM ttAll GENERAL INSTRUCTIONS: SECTION 2711 OF TITLE 23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS,AND SECTIONS 25286.2-5297,AND,25289 OF CHAPTER 6.7,DIVISION 20,CALIFORNIA HEALTH AND SAFETY CODE REQUIRE OWNERS TO APPLY FOR AN UST OPERATING PERMIT. 1. One FORM"A"shall be completed for all NEW PERMIT CHANGES or any FACIIM/SITE 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 AGENCY UNDERGROUND TANK INSPL 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument,you are making 3 copies. 6. Tank owner must submit a facil ity 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 state financial responsibility require 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/SI'Z'E 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 obde. 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 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,checkvthe 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. V H. PROPERTY OWNER INFORMATION&.ADDRESS(MUSTBE COMPLETED) Complete all items in this section,unless all items are the sante as:SECTION 1;If the same,write"SAME AS SITE"across this'section. Be sure to check PROPERTY OWNERSHIP'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 TYPE box. IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER(,MUST BE COMPLE'TE11 SEE ARTICLE 5,CHAPTE-WA.75,. DIVISION 20,CALIFORNIA HE-AL.TI I AND SAFE'L'Y CODE.) Enter your Board of Equalization(1301.,)UST storage fee account number which is requited before your permit application can be processed. - Registration with the BOE will ensure that you will receive a quarterly storage fed return in reporting-the$0.006(6mills)per gallon fee due on the number of gallons placed in your UST's. The BOL:will code Persons exempt from paying the,storage fee so returns will riot be sent. If yoU do not have an account mtmbcr with the BOE or if you have any questions regarding the fce'orexc�iptioms,please call:the BOF at 916-322-9669 or write to the BOL.,at the following address Board of Equalization,Fuel Taxes Division,P.O.Box 942919,Sacramento,CA 94279-0001. V. PETROLEUM UST FINANCIAL RESPONSIBILITY(MI:ST BE COMPLETED FOR PE"I'ROLEUM.USTs ONLY,SEE SUCTIONS 2711(a)(S) OF'IITLI::23,CHAPTER 16,CALIFORNIA CODE OF REGULATIONS.) Identify the rnethod(s)used by the owner and/or operator,in Wresting the Federal and State financial resportsibility requirements.UST,owned by any Federal or State agency as well as non-petroleum UST's are exempt from this requirement. VI.LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE 13OX for the address that will be used for BOTH LEGAL..AND BILING 1403•IFYCATIOtiS. TANK OWNER OR AUTHORIZED REPRESENTATIVE MUST SIGN ANTI)DATE THE FORM AS INDICATL D. (SEE SECTIONS'2711 (a)(13)OFIITLE 23 CHAPTER 16,CA11FOR\IA CODE OFREGULATIONS.) INSTRUCTION FOR THE LOCAL AGENC IE'S The county an jurisdiction numbers are predetermined and can be obtained by culling the 94'H®arj!{916}221<4303. The:factlity number may be assigned by the local agency;however,this number must be numerical and cannot contain any alphabetical characters. If the 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 TILE ACCURACY OF.THE INFOR-MATION. THIS APPLICATION CANNOT BE PROCESSED IF THE BOE ACCOUNT NUMBER IS NOT FILLED IIF. THE LOCAL AGENCY IS RESPONSIBLE FOR THE COMPLETION OF THE "LOCAL AGENCY USE ONLY" INFORMATION BOX AN70 FOR FORWARDING ONE FORM"A"AND ASSOCIATED FORM"B"(s)TO THE FOLLOWING ADDRESS. THE LOCAL AGENCY SHOULD RETAIN TTIL ORIGINALS AND FORWARD THE YELLOW COPIES TO THE FOLLOWING-ADDRESS.THE PINK COPY SHOULD BE RETAINED BY THE TANK OWNER. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O S.W.E.E.P.S. DATA PROCESSING CENTER P.O.BOX 527 PARANIOUNT,CA 90723 3/93 FOR0120R1