COMPLIANCE INFO_2005-2008 - Laserfiche WebLink

Home Browse Search

UST- Facility Form Instrpctions (F rmerly SWRCB UST Permit Application for . ) Complete this form for all new permits,permit changes, or any facility information changes. This form must be submitted within 30 days of permit or facility information changes,unless your local agency requires approval prior to making changes. Submit one UST-Facility form per facility,regardless of the number of tanks located at the site. If not already on file with the local agency, the tank owner must submit, with this permit application, a current UPCF UST - Tank form for each tank; written UST Monitoring Plan; UST Response Plan; and, for tanks containing petroleum, UST Certification of Financial Responsibility. Please number all pages of your submittal. (Note: Numbering of these instructions follows the UPCF data element numbers on the form.) 1. FACILITY ID NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter the complete Facility Name. 400. TYPE OF ACTION-Check the reason why this form is being submitted. CHECK ONE ITEM ONLY. 401. NEAREST CROSS STREET-Enter the name of the cross street nearest the tank location. 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 that will remain 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 name of the supervisor of the division,section, or office that operates the UST. This person must have access to the tank records. 407. PROPERTY OWNER NAME- Complete items 407-412 for the property owner, unless all items are the 408. PROPERTY OWNER PHONE- same as the Owner Information (items 111-116) on the Business 409. PROPERTY OWNER MAILING OR STREET Owner/Operator Identification page (OES Form 2730) in the facility's ADDRESS- Hazardous Materials Business Plan. If the same, write "SAME AS 410. PROPERTY OWNER CITY- SITE" in this section. For phone numbers, include the area code and any 411. PROPERTY OWNER STATE- extension number. 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 same 415. TANK OWNER PHONE- as the Owner Information (items 111-116) on the Business 416. TANK OWNER MAILING OR STREET Owner/Operator Identification page (OES Form 2730) in the facility's ADDRESS- Hazardous Materials Business Plan. If the same, write "SAME AS 417. TANK OWNER CITY- SITE" in this section. For phone numbers, include the area code and any 418. TANK OWNER STATE- extension number. 419. TANK OWNER ZIP CODE- 420. TANK OWNER TYPE-Check the type of tank ownership. 421. BOE NUMBER-Enter your State 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, contact the BOE at(916)322-9669 or by mail at: Board of Equalization,Fuel Taxes Division,P.O.Box 942879, Sacramento,CA 94279-0030. 422. PETROLEUM UST FINANCIAL RESPONSIBILITY-Check the method(s)used by the UST owner/operator to meet Federal and State financial responsibility requirements. CHECK ALL THAT APPLY. If a method you use is not listed, check"Other" and specify the method(s)used. Non-petroleum USTs and all USTs owned by Federal and State agencies are exempt from this requirement. 423. LEGAL NOTIFICATION AND MAILING ADDRESS - Indicate the address to which legal notifications and mailings should be sent. 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 the form was signed. 425. APPLICANT PHONE-Enter the phone number of the applicant(i.e.person certifying).Include the area code and any extension number. 426. APPLICANT NAME-Print or type the full name of the person signing the page. 427. APPLICANT TITLE-Enter the title of the person signing the page. 428. STATE UST FACILITY NUMBER-This space is for agency use only. 429. 1998 UPGRADE CERTIFICATE NUMBER-This space is for agency use only. UPCF Hwfwrc-a(1/99)-2/2 http://www.unidocs.org Rev.02/16/00