COMPLIANCE INFO_1985-2007 - Laserfiche WebLink

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iNsTRucnoNs FOR comnEuNG FC) RM W GENERAL INSI'RU(:11ONS: L Onc FORM "A' shall be cnnipbeted for all NEW PERWIN, PERMIT CIIANG"_' or any FAC1111,YISITU 2. SUBMIT ONJN ONE (1) =,'OIZM W for a Facility/Sitc, regardless of the munber of tanks located at the hike. 3. t, ! m should be complcwd bY, either the PERNMFF APPLICANT or the LOCAL AGENCY UNDI W;IZOLTNI) TAN -K iNS1111(70R 4. dearly all requested information. 5. Us„, writing instrument, you are making 3 copies. Mark an (X) in the box next to the item that best describes the reason the form is being completed. 1. ]FACIIrIYJSr1B INFORMN11014 & ADDRESS (MUST BE COMPIH17ED) L Record name and address (physical loxation) of the underground tank(s). NOTE: Address %I L'S V ho,,,e a valid physwal location including city, state, and zip code. P.O. BOX NUMIDER's ARE NG-- ACCIWABLE. Include nearest tno;s street ai;,, - ase of the operator. 1 Phone nuhlber atz<>t have an area code, night munber is the same, write "SAME” in proper location 3. Check the r lir peiace box for TYPE 01, OWNERSHIP (ex. CORl'ORA'IJON, INDIVIDUAL etc.) 4. Check the appropriate box for TYPE OF S. 5. If Facility/Site is located within an Indian reservation or other Indian trust lands, check the box marked "YES". 6. Indiwail the NUMBER of TANKS at this SITE,, 7. Record the E.P.A. ID # or write "NONE' in the space provided. IL PROPERTY OWNER INFORMA17ON & ADDRF-SiS (MUSF BE COMPLEI`1) ' Complete all items in this section, unless all items are the same as SECTION 1; if the same, write ME, A,'; S11V. Tons this section. Be sure to check PROPERTY OWNERSHIP TYPE box. III. TANK OWNER INFORMN110N & A0DRF_SS (MUS -1- BF COMPLLTI`I?D) Complete all items in this section '01, items %€'- the same as SECTION 1; If the same, write 'SAME AS SHE" across this section. Be sure to check TANK OWN111 ,.KSI1HfYPE box. IV. BOARD OF EQUAI"ATION UST STORAGE FEE ACCOUNT NUMBER {MUST' BE COMP11-J1710) Enter your Board of Equalization (DOE) UST storage fee account number which is required before your permit application can be processed. Registration with the DOE 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 DOE will code. persons exempt from paying the storlge, fee so turn,,. will ot be sent, If you do not have an account number with the DOE or if you have any\ questions regarding thcffeeor exemptions, please call & DOE at 916-323-9555 or write to the DOE at the following address Board of Equalization, Environmental Fees Unit, P.O. Box 942879, Sacramento, CA 94279-00Q7.: V. PETROLEUM UST FINANCIAL RESPONSIBILrrY (MUST BE COMPLETED) Identify the rhethod(s) used by thd 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. VI. LEGAL NOTIFICATION AND DIIIING ADDRESS Check ONE BOX for the address that will be used for BOTH LFGAL AND BUJING NO11FICA'ITONS. APPIJCANT MUST SIGN AND DATE THE FORM AS INDICATID. IN.STRUC`nON FOR THE WCAL AGENCIES The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-242l.. The facility number may be assigned by the local agency; however, this number must be numerical and cannot contain any \4 alphabetical. If the local agency prefers the St,-.ve Board to assign the facility number, please leave it blank. rr tsnjul RmPoNsuoury OF nw. LOCAL TINE FACILITY"TOVERIFY'niE ACCURACY OF'I1JE INFORMATION. '1111S APPLICA170N CANNOT BE" PROCESSEI) JFME DOE A(X,'OUlql' NUMBER IS N()'f' FILLED IN. IT -W, LOCAL AGENCY IS RESPONSIBLE, FOR 11IL COMPLE'11ON OF TIJI.-I "LOCAL AGENCY US17 ONLY" INFORMN11ON BOX AN]) FOR FORWARDING ONE FORM W AND ASSOCIATED IX)RM W(s) TO THE FOIWWtN(; Al_.)DRE_S sTATE OF CAIJFORNIA STATE WAIT R0SOURCFS COWROL BOARI) CX) &W.Iuip.S. I)AFA PROCEMING CENFER P.O. BOX 527 PARAMOUN7.17, CA 90723