COMPLIANCE INFO_1985-1997 - Laserfiche WebLink

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• 1, One FORM "A" shall be completed for all NEW PERM1715, PERMrF 01ANGIT-S or any FACH11-Y/SrIM 1NFORMA7nON CHANGES. 2. sumrr 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 LOCM. AGENCY UNDE"RGROUNDTANK !N,SPFA-I'OR- 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. TOP OF F()RM: 'MARK ONLY ONE TEM' 1. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 1. FAC.11XI-Y/Stfl-14 INFORMATION & ADDRESS (MUST BE mmeu-no) L Record name and address (physical location) of the underground tank(s). NOTE., Address NMUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBER ARE NOTACXUPTABLE. 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 on land within an indian reservation or other Indian trust lands, check the box marked "YTS". 6. Indicate the NUMBER of TANKS at this SITF- 7. Record the E.P.A. 11) # or write " TONE" in the space provided. It. PROPERTY OWNER INFORMAT]ION & ADTI-R!,RS (MUST BE COMPUNI--?D) 1. Complete all items in this section, unless an items are the same as SECTION 1: if the same, write 'SAME AS SI'11* across this section. Be sure to check PROPERTY OWNERSHIP TYPE bo"X. III.TANK OWNER INFORMATION & ADDRESS (MIJIMBE COMPLE11-111) 1. Complete all items in this section, unless s;Ii ;--m<a-C the same as SECTION 1; If the same, write *SAME AS SITE" across this section. Be sure to check "'ANK 4I WNTRSIBc TYPE box. IV BOARD OF IX)UAUZKIION 1,1`1;," NUMBER (MUSS' BE COMPIrI10) Enter your Board of Equalization (13011.) 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 int reporting the $0,000 (6 mills) per gallon fee due on the number of gallons placed in your U91's. The BOE will code persons exempt from paying,the storage fee so returns will not be sent. If you do not have in account number with the 11011 . . or if you have any questions regarding the fee or exemptioos, please all the BOI, at 916-739-2582 or write to the BOE at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 9-12879, Sacramento, CA 94279-0001. V. 11XiA1. NOT][FICATION AND 11111ING ADDRESS 1. Check ONE BOX for the address that will be used for 13 111 IlXiAl, AND BILLING N(f][IFICATIONS. AiTl AND DATE `1"11F FORM AS INDICATED. INSil- "(71-R N "ORTNE IO(:AL AGINCIUS The county and jurisdiction nvnibers, are predetermined and can be obtained by calling the State Board (916)739-2421. The facility number may be assigned by the local iaenc%: ha -never, this number must be numerical and cannot contain an alphabet. If the local agency prefers the State Board to assign the facility number, please leave it blank. IT IS17IR RESPONSIBUATY OF'111E IA.X:AL AGENCY ITIAT 1NSPEC7rS'111E FACIMYTO VERIFY 111E AC0URAC'Y OF1711-7 M?OPZMATION. TIMS APPIJ(W17ON (:ANNorr BE PRocussi:70 IF'171E BOE ACC ()LWr NUMBER IS NOT IN. TIIE LOCAI, AGINCTY IS RESPONSIBLE IK)R'nJE C.()MPW,.nON OF111E"LOCAL AGIINC'Y USI! 0NLY'INlk)R1%4X11ON 13OX AND FOR FORWARDING ONE FORM *A* AND ASSOCIA7170 FORM *B"(s) TO 111E FOI1.OWING ADDRESS. S`NIE OF CALIFORNIA 91WI1i WATER RESOURCES CONTROL BOARD C/o &W.IUIP.S. DA'T'A PRO(MSSING C124TER P.O. BOX 527 -YARAMOUNT, CA 9VM