COMPLIANCE INFO_1989-2005 - Laserfiche WebLink

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xsc-.v<=rss.:,a. s - ,E „ter , =t4 - i T 7 - ^mom*«F��r..s,-. -•�*m� �, �"" �i� a.�':2n---- -nm Y.- �^"8e"'�+.�,- r'; ,k,,.,: _ �.. INSTRUC11ONS FOR COMPI.,ENING FORM "A" GENERAL INSTRUCTIONS: FORM "A" shall be completed for all NEW PERMITS, PFRMIT' CEIANGFS or any FA0I.rTY/sr1l? z t' 110N (,HANGI 2.. SUBMIT' ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number o tanks located at thz site. sl, ,Id be completed by either the PERMIT APPI.IC,ANT or the LOCAL AGENCY UNDITGIZOUNI TANK INSPECTOR- 4. NSPECTOR4. Please type or paint clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. TOP OF FORM: "MARK ONLY ONE ITEM" -lark an (X) in the box next to the item that best describes the reason the form is being completed. 1. FAC:1111'Y/SITE INFORMATION& ADDRESS (MOIST BE COMPL.I:IED) 1. Record name and address (physical location) of the underground tank(s). NO'fI3: Address MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARE NOT AC"C "TABU? 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 COMPLE-171)) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write ".SAME AS Sr17? 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 arc the same as SECTION 1; If the same, write *SAME AS STET,." across. this section. Be sure to check TANK OWNERSHIP TYPE box. IV. BOARD OF EQUALIZATION USI'STORAGE FEE ACCOUNT NUMBER (MUST BE COMPI.ulrro) 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 UST's. 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 BOF or if you have any questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOF, at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001, V. PUFROLEUM UST FINANCIAL RESPONSIBILITY (MUST BE COMPLETED) 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. VL LEGAL NOTMICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH LEGAL AND BILUNG NOTIFICATIONS. APPLICANT MUST SIGN AND DATE'TILE FORM AS INDICATED. INSTRUCTION FOR 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 TILE RESPONSiBRX17Y OF THE LOCAL,AGENCY TIIAT INSPECTS TILE FACEIITY TO VERIFY TIi1 ACCURACY OFTHE INFORMATION. THIS APPLICA'T'ION CANNOT BE PROCESSED IF THE BOE ACCOUNT' NUMBER IS NOT FILLI3D IN. T'HE IACAL AGENCY IS RESPONSIBLE FOR TIIE COMPLETION OF TILE 'LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR]FORWARDING ONE FORM "A" AND ASSOCIATED FORM "13"(s)TO 'TIIE FOLLOWING ADDRESS. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/O S.WXU4-P.& DATA PROCESSING CENIER P.O. BOX 527 PARAMOUNT, CA 90723 i