Form 38-0012 Dpw - Hazardous Substances Underground Storage Permit Application Supplement / Notice To File Authorization To Maintain Underground Storage Tanks
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1
2DPW USE ONLY:
FORM VALID JULY 1, 2017 TO JUNE 30, 2018
SITE-FILE NO.: ______________________AREA____
HAZARDOUS SUBSTANCES UNDERGROUND STORAGE PERMIT
APPLICATION NO. ____________________________
APPLICATION SUPPLEMENT / NOTICE TO FILE
AUTHORIZATION TO MAINTAIN UNDERGROUND STORAGE TANKS
COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS
ISSUED PERMIT NO.: __________________________
Environmental Programs Division
rd
900 South Fremont Avenue, 3
Floor Annex Building
DATE REC’D. ___________ BY __________________
Alhambra, CA 91803-1331
(626) 458-3517, Fax (626) 458-3569
CHECK [ ]
CASH [
]
FEE $ _______________
Application is hereby made for authorization to operate and maintain underground storage tanks (UST). This form must accompany each UST
permit application for a new Hazardous Substances Underground Storage Permit or Unified Program (UP) Facility Permit.
** See instructions on back of this form**
CALIFORNIA ENVIRONMENTAL REPORTING SYSTEM (CERS) ID#_________________________
Email address of UST owner/operator or representative: ________________________________________________________________________________
FACILITY ADDRESS INFORMATION
UST OPERATOR, IF NOT UST OWNER NAMED ON UP FACILITY FORM
FACILITY NAME
OPERATOR NAME
FACILITY ADDRESS
OPERATOR MAILING ADDRESS IF DIFFERENT FROM FACILITY ADDRESS
CITY
ZIP
CITY
STATE
ZIP
NUMBER OF USTS TO BE PERMITTED AT FACILITY: _____________ FEDERAL TAX ID NO: _____________________ SIC CODE: ___________________
ASSESSOR PARCEL NUMBER (APN): MAP BOOK NO. _____________________ PAGE NO. ____________________ PARCEL NO. __________________
BUSINESS ENTITY NO.__________________________
THIS SUPPLEMENT MUST BE ACCOMPANIED BY:
▪
▪
SUBMITTED FACILITY INFORMATION
SUBMITTED DESIGNATED OPERATOR FORM
▪
▪
SUBMITTED TANK INFORMATION (ALL USTs)
SUBMITTED FINANCIAL RESPONSIBILITY FORM (Petroleum USTS)
▪
▪
SUBMITTED MONITORING INFORMATION
SUBMITTED UST RESPONSE PLAN FORM
▪
▪
OPERATING PERMIT APPLICATION FEE
PRO-RATED ANNUAL PERMIT MAINTENANCE FEE
:
HSUSP FEE SCHEDULE
(Los Angeles County Code 11.82.010)
NUMBER
OPERATING PERMIT
*PRO-RATED ANNUAL PERMIT
OF USTs:
APPLICATION FEE
+
MAINTENANCE FEE*
1
$554.00
$1,554.00
2
$649.00
$1,804.00
3
$744.00
$2,054.00
4
$839.00
$2,304.00
5
$934.00
$2,554.00
6 or more tanks
$459.00 + $95.00 per tank = $_________ + $1,304.00 + $250.00 per tank = $__________
MAKE CHECKS PAYABLE TO: “COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC WORKS”
*See Back of form for Pro-rated Annual Permit Maintenance Fee factors.
This Hazardous Substances Underground Storage Permit application form with the Permit Number identified in the upper right hand corner will
serve as the UST operating permit document until the Unified Program Facility Permit is issued by the County of Los Angeles Certified Unified
Program Agency the following Fiscal Year. All fees must be paid prior to issuance of the UP Facility Permit authorizing the underground storage of
hazardous substances.
UST OWNER/OPERATOR REPRESENTATIVE MUST COMPLETE THIS SECTION (AND BACK OF FORM):
SIGNATURE ______________________________________________________ TITLE _______________________________________________________
PRINT NAME _____________________________________________________ DATE _______________________________________________________
PAGE 1 of 2
Complete Certification of Compliance with County of Los Angeles Lobbyist Ordinance on back
38-0012 DPW Rev. 07/17
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