COMPLIANCE INFO_1987-2001 - Laserfiche WebLink

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. .: _ 4 we t `f3 INS1'RUC."TTONxS MR COMPLETING FORM *A" G ;ICAC. S17RUCATONS; 1. One FORM "A"shall be completed for all NM PERWIN, PERMIT CHANGES or any FACIIXl'Y/S1TF, ENF4BRMNITON CHANGES. 2, SUBMIT ONLY ONE (1) FORM "A" for a Facility/Site, regardless of the number of tanks located at tile. site. 3. This form should be completed by either the PERMFI'APPI.IC,A T or the LOCAL AGENCY 1.?NDFIR iROl."NI) TANK INSPE(7.POR. 4, Please type or print clearly all requested information. 5. Use a hard point writing instrument, you are staking 3 copies. TOP OF EaC)RW "MARK ONLY ONE I"I`l:W ?Mark an (X) in the box next to the item that best describes the reason the form is being completed. I. FACILYI-Y/STIE 1N1[`ORM141.ION.Sc ADDRESS: (MUST BE COMPLETED) 1. Record name and address (physical location) of the underground tank(s). NO'I"F: Address MUST' have a valid physical location including city, state, and zip code. P.O. BOX NUMBERS ARE NOT AC(MVFABI E7 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 tine appropraam box for TYPE OF BUSINESS OWNERSHIP (ex. CORPORA'110N, INI)IVII)I Al- 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 "YT-1s". 6. Indicate the NUMBER of,TANKS at this SCI'1s. 7. Record the EYA. 1.1) # or write "NONE" in the space provided. II. PROPEIrrY OWNER R I. R `17ON&ADDRESS ST BE (X)MPL--,n.)) l" 1 Complete all items in this section, unless all items are the same as SI3cri:ON 1; if the sante, write "SAME AS SrIT:" across this section. Be sure to chink PROPERTY OWNERSHIP TYPES box. W, 'TANK OWNEM fMX)IaMSITON & A137 KERS (MUS"I`BE COMPLE'WED) Complete all items in this section, unless all items are the same as SE',C FR)N 1; If the same, write ',SAME3 AS SIt'E"across this sc°ction. Be sure to check TANK OVINURSIRPTYPE box. IV. BOARD OF EOUAIXZA77ON USTSTORAGE FFEF ACCOUNT ER S.I°BE CO E'L 110) Enter your Board of Equalization (BOL) UST 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 USI's. The BOE will code person,,; 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 130E at 916-323-9555 or write to the BOE at the following address: Board of Equalization, Environmental Dees Unit, P.O. Box 942579, Sacramento, CA 94279-000L V. PT T'IC0LFUM USI'HNANCIAL RE SPONSIBILI[TY (MEdST BE COMPLE rm) Identify the method(s) used by the owner and/or operator in meeting the federal and State financial responsibility requirements. UST's owned by any Federal or State agency are exempt from this requirement. VL I,ECIAL NOT IM(WFION AND BILLING ADDRESS Check ONE BOX for the address that will be used for BOTH 1.Et" L AND E1 NU NOTIFIC NI[IONS. APPIICANT MUST SIGN AND DXFF THE FORM AS INDICATED, SI'IC1.1C"ION FOR'171E?LOCAL AGENCMS The county and jurisdiction numbers are predetermined and can be obtained by calling the State Board (916)739-242'1. 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. r IS nip ICES N ISI n-Y ore IIID I, cAI,AGFNC'Y T IAT INSPEC'I'S'11111 FACII kI'Y TO $ THE ACCURACY OFr`:I`IIE? 1 1FOR TION. '1111S APPLICATION CANNOT BE PROCESSED EF T1W BUIE AC UN r NUMBER IS NOT 141.,111) IN, 311E LOCAL AGENCY IS RI SPONSI[BLE FOR.1111E COMP1,E`I10N OF THE '1,OC<AL AGFN("Y° USE ONLY' INFORMN)ION BOX AND FOR FORWARDING ONE FORM "A"ANIS A.x SOC A'IT I) l ) "B"(s)TO IBIS 11011,0 NG AI DRE-s& STA'1Ti OF CAI,II3ORNIA STATT" WATER RESOIIIZC"I:.S COWROL BOARD C/0 S. .IuP 1-a. DATA PROCESSING C NIER P.O. BOX 527 PARAMOUE-17, CA 90723 + s� !i: