COMPLIANCE INFO_1993-1994 - Laserfiche WebLink

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7- INSMUC11ONS FOR COMPLETING FORM 'A7 GENERAL INSIMUCTIONS- A. One FORM "A" shall be completed for all NEW PERMITS,, PEitmi'r CHANGES or any FACIIXl'Y/SrIV. 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 UNDFR(jROUNI) TANK INSPECTOR 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are making 3 copies. 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. FACILTI'Y/SM,INFORM[NnON & ADDRESS(MUST BE COMPLF!JrED) 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 code. P.O. BOX NUMBERS ARE NOT Acr=ABLIi 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 "YFS". 6. Indicate the NUMBER of TANKS at this SfTE. 7. Record the E.P.A. ID # or write "NONE" in the space provided. H. PROPERTY OWNER INFORMATION&ADDRESS (MUST BE.COMPLUFFD) Complete all items in this section, unless all items are the same as SECTION 1; if the same, write "SAME AS Srl'li" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. M. TANK OWNER INFORMA11ON &ADDRESS (MUST BE COMPLU114,D) Complete all items in this section, unless all items are the same as SEC`nON 1; If the same, write 'SAME AS S111i across this section. Be sure to check TANK OWNERSIIIP TWE box. IV. BOARD OF EQUAL17ATION UST STORAGE FEE ACCOUNT NUMBER(MUST BE COMP11--110) Enter your Board of Equalization (BOE) USI'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 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 BOE or if you have any questions regarding the fee or exemptions, please call the BOE at 916-323-9555 or write to the BOE at the following address: Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PETROLEUM 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. USFs owned by any Federal or State agency are exempt from this requirement. Vt. LEGAL NOTIFICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTTI LFIGAL AND BI11JNG NO71MACK11ONS. APPLICANT MUST SIGN AND DATET[IE 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)7.19-2421. 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 THE RFSPONSIBIIXJrY OFT[IE LOCAL AGENCY THAT INSPECIN IIIE FACILITY TO VERIFY ITIE ACCURACY OF THE INFORMATION. ITHS APPLICATION CANNOT BE PROCESSED IF THE DOE ACCOUNI' NUMBER IS NOT FILLED IN. THE LOCAL AGENCY IS RESPONSIBLE FOR TIIE COMPLETION OF .LOCAL AGENCY USE ONLY' INFORMNI'ION BOX AND FOR FORWARDING ONE FORM "A"AND ASSOCIKIMD FORM "B"(s)TO THE FOLLOWING ADDRESS. STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD C/o &WILE.Ps. DATA PROCESSING CENTER P.O. BOX 527 PARAMOUNT!, CA 90723