COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

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INSFRUC;TIONS FOR COMPLETING FORM "A" GENERAL INSi.'RUCIT()NS- 1. One FORM "A" shall be completed for all NEW PE IN, PERMIT CIIANGES or arty 1FAC:II,I"TY/SI'm INFORMiVITON CHANGES. 2, SUBMIT ONLY ONE(1) FO "A" for a Facility/Site, regardless of the number of tanks at th�" site. 3. This form should be completed by either the PERMIT APPIJCAN`F car the LOC:AI.AGENCY UNDI;F GIZO)Us4l) TANK INSPECTOR. 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. `I'COP OF 1FC) . ":.MAIM ONLY C?19dE ITEM" Mark an (X) in the box next to the item that best describes the reason the form is being completed. I. IFAC:ILFrY/SII'L3 INIFORMN11ON & ADDRE S (MUST BE (X)MPL rrE:D) 1.. Record name and address (physical location) of the underground tank(s). NOTEAddress MUST have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARE NOT ACC1-tV ABtJ 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 "SA-Mf,"' in proper location. 3. Check the appropriate box for TYPE OF BUSINESS OWNERSHIP (ex. C( UIORA'TIC)N, INI)IVII)U 1- e1c.j 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'I'ANI(S at this SITE, 7. Record the ETA, ID # or write "NONE" in the space provided. H. PROPERTY OWNER INFORMKnON t& DRP—SS (MUST BE COMPLt"'MD) Complete all items in this section, unless all items are the same as SECTION 1; if the same. write "SAIME AS SHV` z€cross this section. Be sure to check PROPEWFY OWNERSHIP TYPE box. III. TANTS OWNER INFORMATION &ADDRESS (MUSI'BE (:Y)MPI.I?I.'I D) Complete all items in this section, unless all items are the same as SEC'I10N 1; If the same, write 'SAME AS SI'I'I across this section. Be sure to check TANK OWNP` SI `I E box. IV. BOARD OF F.QUAt.I"Z,A'ITON USI"S`In GE T?E ACCOUNT NUMBER(MUST BE C.OMPt.t<ITD) Enter your Board of Equalization (BOF) US`F 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 50.006 (6 mills) per gallon fee due on the number of gallons placed in your USTs. The 'BOF will code persons exempt from paying the storage fee so returns will not he 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 916-313-9555 or write to the BOE at the following address: Board of..liqualization, 1an-6ronmental T=ees Unit, P.O. Box 942£37), Sacramento, CA 94279-0001, V. PI:FROL,1 UM UST FINANCIAL RISPONSII3II.TI"Y (MUSxT BE coMPIj;I"Ir:I)) 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 front this requirement, VI. 1.11GAT, NOTIFICATION AND BILLING ADDRESS Check. ONE BOX for the address that will be used for BOTII LIXiAL AND BUJ ING NOTIFICATIONS. APPLICANT MUST SIGN AND DATE TIII FORM AS INDICATED. INSI'RUCIION FORTRE LOCAL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-2421. 1-he 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 lead it blank. Il'IS THE RES N'913111ff OF 771F LOCAL AGENCY THAT INSPEC.'I`S'111E FACILITY TO d/® II?Y'171W, ACCURACY OF THE INIFORMADOM TINS APPLICATION CANNOT BE PROCESSE4) IIF THE BOE A(a('OUNI' NUMBER IS NOT FILLET) IN. 1IIE LOCAL AGINCY IS RFSPONSH3111 POR'IME COMPLE`T'ION O1F TIII? *LOCAL AGUNC:"Y USE ONLY" INFORMN171ON BOX AND 17OR(FORWARDING ONE FORM "A"AND ASSOC IA TFJ) (FORM "B"(s)TO THE FOLLOWING ADDRESS. STA'I1 i OF CALIFORNIA STATE WATER RESOURCES N'I'ROL BOARD C/o sm y I?P 9, D;A")'tY PRoc SING 1;R P.O. BOX 527 PARAMOUNT, CA 90723