COMPLIANCE INFO_1985-1997 - Laserfiche WebLink

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INSTRUCTIONS FOR COMPLI::TING FORM GENERAL INSTRUC717ONS: L One FORM "A" shall be completed for all NEW PERMITS, PERMIT C",EIANGIS or any FACIE.rl'Y/SF1'E INI1ORMA17ON CIIANGI S. 2. SUBMIT ONLY ONE (1) 17ORM "A" for a Facility/Site, regardless of the number of tangs localcd ,,t ahc '111 3. T'hi's form should be completed by either the PERMIT APPLICANT or the LOCAL AGENCY UNDFRGROUNI) TANK INSPECTOR. 4, Please type or print clearly all requested information. S. Use a hard point writing instrument, you are making 3 copies. TOP OF FOR]SE "MARC ONLY ONE, 1TIl1Wt" �• r ;a. an (X) in the box next to the item that best describes the reasgtn,t#e'.f'orn,,,is tre)rpjonlpleu;d. - i. L FACi:I.XI-Y/S11T INI►ORMATION&ADDRESS (MUST BE CA)MP'1.1?IM) 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 axle. P.O.BOX NUMBERS ARE NOT ACCEWABIE 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 "SAM.F" in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORATION, INT)FVIDUAL, 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 "YF?S". 6. Indicate:the NUMBER of TANKS at this SITE. 7. Record the E.P.A. 11.) # or'write "NONE" in the space provided. IL PROPER'T'Y OWNER INFORMATION&ADDRESS(MUST'BE CQMWMWJ Complete all items in this section, unless all items are the same as SECTION 1; if the same, write ".SAME AS sm.., across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. TANK OWNER INFORMATION &ADDRESS (MUST BE CONWLEYM) Complete all items in this section, unless all items are the same as SECTION,U,If that*an}e;write 'SAW—,AS,SII7" ac;J,-pss this section. Be sure to check TANK OWNER.SEIIF TYPE box. Iv. tBOARD CIIt EQUALImnoN UST STORAGE FEW.ACCOUNT NUMBER 'B*004w lilrl1'm) i Enter your Board of Equalization (BOE) U91'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 49Its person§ ixempt.,frclm paying the storage fee so returns will not be sent. If you do not have an account number wttl~16 AI or if'you leave any questions regarding the fee or exemptions, please call the BOE at 916-p23-9555,or write o the BOE at the followin address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacf amento,'CA 94271::` } V, PLTROI.EUM,U.ST FINANCIAL.413SPON-413EI TTY QdVST BE COMPLEFrED) 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. LEGAL NOT1171CATION AND BIIIJNG ADDRESS Check ONE BOX for the address that will be used for BOTH I.EGAL AND BII1d41G NOTIFICATIONS. AI TIA(.. NT M,UfiT SIGN AND DA'I lr TETE FORM AS INDICATED. INSSTRUC:TION FOR 11IE LOCAI.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 IMF, RF-ST'OMMXIY OF THE:LOCAL AGENCY THAT INSPFICIIS TEIE FACUIY TO VERIFY THE: ACCURACY OF THE INFORMATION. TATS APPLICATION '-.8L-P ED IF THE BOE?ACCOUNT NUMBER IS NOT FILLED IN. TETE LC AL�GENC.Y d9 RESPONSIBLE FOR TW WC W'E,1`QN-CUFF 17I1? v 'LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR FORWARDING FORM WAND ASSOCIATED FORM "B"(s)'IY3 THE FOLLOWING ADI: R S& S1ATE OF CALIFORNIA STATE WATER RFSOURCTS Ct:)NIROL BOARD C/o S,.W_EF-ps. DATA PROCESSING CI NI'ER P.O. BOX 527 PARAMOUNT, CA 90723