COMPLIANCE INFO_1985-1997 - Laserfiche WebLink

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INSFRUCIIONS FOR COMPL.;. NCI FORM "A" GENERAL LNSI'RU r . ONS: 1, BOOM "A" shall be completed for all'NI. PI Is, PERmrr C>II NCYRS or anv, FAC'ILMY/SFI1, "AiV[I P CI NGF:.S. 2, SU13fd T ONLY ONE (I) FOR "A" for a Facility/Site, regardless of the number of tank's located it t(ic 4fter. sl->Id d be completed byeither the I'Ia27 i'I' T�1' I ANr or the LOCAL AGENCY UPdl)I It(tIZ(IC1;titt STANK INSPI 7'C)I2 4. Please type or print clearly all requested information. 5. Use a hard point writing instrument, s-ou are making 3 copies. I" OF FORM- "MARK ONLY ONE ITEW `.kmk an (X) in the box next to the item that best describes the reason the forth is being completed. I. PA(. -J/S "170N& ADDRESS ( SI'BE COMP11,170) 1. Record name and address (physical location) of the underground tank(s). NOTE: Address MUSThave a valid physical location including city, state, and zip code, P.O. BOX NUMBERS ERS ?NCI'I"ACCIWABUL 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. CORPOI2r TION,INDIVIDUAL, etc.), 4. Check the appropriate box for TYPE, OF BUSINESS. S. 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 SITE. : 7. Record the ETA. ID # or write "NONE" in the space provided. 11. PROPEWrY C3 C)N&ADDRum (MUST BE CCI `J ) Complete all items in this section, unless all items are the sante as SF,C CION 1; if the same, write 'S S IT AS SFI*E" across this section. Be sure to check PROPERTY OWNERSHIP TYPE box. M. TANK OWNER INFORMATION &AIIDRF-SS (MUST`BE COMPLETEM) Complete all items in this section, unless all items are the sante as SECTION 1; If the same, write 'SAME AS S,fff. across this section. Be sure to check TANK OV0113RSHIP TYPE, box: IV. BOARD OF EQUALTYWHON I1. SIS GIT F$°'E ACCOUNT USI"BE COMPIit i°, ) Enter`your Board of Equalization (130F.) LIST storage fee account number which is required before your permit application can be processed. Registration with the BOE's urill 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 T,,"STs. 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 witb 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 Pees Unit, P.O. Box 942879, Sacramento, CA 94279-0001. V. PH 1'RQLEUM UST 14MANCTAL RESPONSIBILITY (MUST BE C OMPL t)) Identify the method(s) used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. USI's owned by any Federal or State agency are exempt from this requirement. VI. LEGAL NGITFI ATICIN AND BILLING ADDREWS Check ONE, OX for the address that will be used for Ia;C7°IH LEGAL AND PALLIM N01MCATIONS. APPLICANT' MUW SIGN AND ISA a FORM AS INDICNIED. SI"ICIICI°IC)N FOR THE LOCALAG. 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 7I71F RE-SP0NM3ffir1'Y OF THE LOCAL AGENCY "1"I-IAT INSPBM 111E FACILITY TO 'nJ1 m ACCURACY OF THE INFORMAITON. ITTIS ApPLicKnON CANNOT BE PROCESSFD IF THE BOB AC(Y)UNI NUMBER IS NOT FIIJ...ED IN, TEIE LOCAL AGENCY IS RESPONSEBLE3.FOR WE COMPLEITON OF iE *LOCAL AGENCY USE ONLY" INFORMATION BOX AND FOR:FORWARDING ONE FORM "A"AND C) 1141) FO "B"(s)TO 111E IAC) NG ADDRESS. 51A'I'I OF CALIFORNIA IMATE' AI R RESOURCES CONTROL BOARD C/o Sam r $ .5 DATA ISI O a"'INS . P.O. BOX 527 PARAMOUNr, CA W723 ":