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i . . 0 Formerly SWRCB Form A. UST-Facility Complete the UST-Facility page for all new permits,permit changes or any facility information changes. This page must be submitted within 30 days of permit or facility information changes,unless approval is required before making any changes. Submit one UST-Facility page per facility,regardless of the number of tanks located at the site. This form is completed by either the permit applicant or the local agency underground tank inspector. As part of the application,the tank owner must submit a scaled facility plot plan to the local agency showingthe location of the USTs with respect to buildings and landmarks[23 CCR§2711(a)(8)1,a description of the tank and piping leak detection monitoring program 123 CCR§2711(a)(9)],and,for tanks containing petroleum,documentation showing compliance with state financial responsibility requirements[23 CCR§2711(a)(11)]. Refer to 23 CCR§2711 for state UST information and permit application requirements. (Note: the numbering of the instructions follows the data element numbers that are on the UPCF pages. These data element numbers are used for electronic submission and are the same as the numbering used in 27 CCR,Appendix C,the Business Section of the Unified Program Data Dictionary.) Please number all pages of your submittal. This helps your CUPA or local agency identify whether the submittal is complete and if any pages are separated. 1. FACILITY ID NUMBER-Leave this blank. This number is assigned by the CUPA. This is the unique number which identifies your facility. 3. BUSINESS NAME-Enter the full legal name of the business. 400.TYPE OF ACTION-Check the reason the page is being completed. CHECK ONE ITEM ONLY. 401.NEAREST CROSS STREET-Enter the name of the cross street nearest to the site of the tank. 402.FACILITY OWNER TYPE-Check the type of business ownership. 403.BUSINESS TYPE-Check the type of business. 404.TOTAL NUMBER OF TANKS REMAINING AT SITE-Indicate the number of tanks remaining on the site after the requested action. 405.INDIAN OR TRUST LAND-Check whether or not the facility is located on an Indian reservation or other trust lands. 406.PUBLIC AGENCY SUPERVISOR NAME-If the facility owner is a public agency,enter the new of the supervisor for the division,section or office which operates the UST. This penton must have access to the tank records. 407.PROPERTY OWNER NAME- Complete items 407-412 for the property owner,unless all hems are 408.PROPERTY OWNER PHONE the same as the Owner Information(items 111-116)on the Business 409.PROPERTY OWNER MAILING OR STREET ADDRESS Owner/Operator Identification page(OES Form 2730). If the same, 410.PROPERTY OWNER CITY write"SAME AS SITE'in this section. 411.PROPERTY OWNER STATE 412.PROPERTY OWNER ZIP CODE 413.PROPERTY OWNER TYPE-Check the type of property ownership. 414.TANK OWNER NAME- Complete items 414-419 for the tank owner„unless all items are the 415.TANK OWNER PHONE same as the Owner Information(items 111-116)on the Business 416.TANK OWNER MAILING OR STREET ADDRESS Owner/Operator Identification page(OES Form 2730). If the same, 417.TANK OWNER CITY write"SAME AS SITE"in this section. 418.TANK OWNER STATE 419.TANK OWNER ZIP CODE 420.TANK OWNER TYPE-Check the type of tank ownership. 421.BOE NUMBER-Enter your Board of Equalization(BOE)UST storage fee account number. This fee applies to regulated USTs storing petroleum products. This is required before your permit application can be processed. 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 BOE at(916)322-9669 or write to the BOE at: Board of Equalization, Fuel Taxes Division,P.O.Box 942879,Sacramento,CA 94279-0030. 422.PETROLEUM UST FINANCIAL RESPONSIBILITY CODE-Check the method(s)used by the owner and/or operator in meeting the Federal and State financial responsibility requirements. CHECK ALL THAT APPLY. If the method is not listed,check 'other"and enter the method(s). USTs owned by any Federal or State agency and non-petroleum USTs are exempt from this requirement. 423.LEGAL NOTIFICATION AND MAILING ADDRESS-Indicate the address to which legal notifications and mailings should be sent.The legal - - -- -- .---notificatiausandmailings will be sent to the tank owner vnlessthe-facility-(box-1)orthe property-owner r(box 2)-is checked. - ---- _ SIGNATURE OF APPLICANT-The business owner/operator of the tank facility.or officially designated representative of the owner/operator,shall sign in the space provided. This signature certifies that the signer believes that all the information submitted is accurate and complete. 424.DATE CERTIFIED-Enter the date that the page was signed. 425.APPLICANT PHONE-Enter the phone number of the applicant(person certifying). 426.APPLICANT NAME-Enter the full printed name of the person signing the page. 427.APPLICANT TITLE-Enter the title of the person signing the page. 428.STATE UST FACILITY NUMBER-Leave this blank. This number is assigned by the CUPA as follows:the number is composed of the two digit county number,the three digit jurisdiction number,and a six digit facility number. The facility number must be the same as shown in item 1. 429.1998 UPGRADE CERTIFICATE NUMBER-Leave this blank. This number is assigned by the CUPA. UPCF(1/99 revised) 9 Formerly SWRCB Form A I