COMPLIANCE INFO_1987-1992 - Laserfiche WebLink

Home Browse Search

INSTRUCHONS FOR COMPLETING FORM "A" GENERAL IINSTRU CONS: 1. One FORM "A" shall be completed for all NEW PERMITS, PERMfI'01ANGIN or any FACfI.n'Y/sf n INFORMKI7ON CHANGES. 1 SUBMIT ONLY ONE (1) FORM "A" for a Facilitv//Site, r(gardlc:=s of the number of tank's located at the site. 1 This form should be completed by citfier the PERMrr APT-11 --i-Ir or the LOCAL AGI-NCy UNDERGROUND TANK INSPECTOR 4. Please type,k or,print clearly all requested.in ormation. Use a hard point writing instrument. -ott ai'-; making 3 copi;.,. TOP 017 FORM- "MARK ONLY ONE ITEM' Mark an (X) in the box next to the item.that b;st describes the rea,,)n the form is being completed. L FACILITY/SITE. INFORMA-17ON&ADDRESS (WISP BE COMPI-E`17;i)) 1, Record name and address (physical location) of the undergr,)unc, :ank(s). NOTE: Address MUST have a valid physical location iricluing city, state, and zip Code. P.O. BOX NUMBERS ART!NOT 1kCCl[1TABLE- Include nearest,.pross street anid name of the operator. 2. Phone number must have.an area code. If the night number is the same, write "SAME" in proper location. 1 Check the appropriate � 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". & Indicate the NUMBER of TANKS at this SITE. 7, , Record the E.P.A. 10 #,or write,"NONE" in the space•-provridcd. IT. PROPS-KrY OWNER l[NF0RM/VnON&ADDRESS (MU.St-BECOMPLUIED Complete all items in this section, unless all items are The same as SECTION 1; if the same, write "SAME. AS Srll,'.' across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. M. TANK OWNER INFORMATION &ADDRESS (muSr-BE, COMPLETED)- Complete all items in this section, unless all items are the same as SECTION 1: If the same, write "SAME AS srm." across this section. Be sure to check TANK OWNERSHIP TYPE box. IV. BOARD OF FOUALIZ/VI'ION UST STORAGE FEEACCOUNT NUMBER (MUST BE COMPIx-17--m) 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 BOF' will code persons exempt from l5ayidgthe storage fee so returns will not be sent. If,y6u do not have an account number with the BOE or it' N'OLI 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. P11,1'ROLEUM UST FINANCIAL RESPONSIBILITY (MUST'BE COMPLE-17ED) Identify the method(s) used by the oAqier and/or operator in meeting the Federal and State financial responsibility requirements. US`rs owned by any Federal or State agency are exempt from this requirement. VL LEGAL NG11FICATION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOT[I LE63AL AND 13111ING NOTIFICATIONS. APPLICANT MUST SIGN AND DATE THE FORM AS INDICATED. INSTRU CON FOR TRE LOCAL AGFNC',S The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (91(1)739-2421. Tie 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 TITE RESPONSIBUXI'Y OF TIIE LOCAL AGENCY 'IIIAT INSPECTS TIJE FACILITY TO VERIFY'111E ACCURACY 017 171E INFORMATION. 1111S APPLICA17ION'CANNOT BE PROCESSED IF ITIE BOI--.ACCOUNI' NUMBER IS NOT FATED IN. TIIE LOCAL A(;I-,NC7Y IS RESPONSIBLE FOR TIIE COMPLETION OF-171311 'LOCAL AGENCY USE ONLY' INFORMATION BOX AND FOR FORWARDING ONE FORM -A" AND ASSOCIATED FORM "B"(s) TO 17JE FOLLOWING ADDRESS. S'I'ATE OF CALIFORNIA SPATE WRIER RESOURCES CONTROL BOARD C/o smiul-p-s. DATA PROCESSING CEN17ER P.O. BOX 527 PARAMOUNT, CA 10723