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UST Operating Permit Application- a ormation Pa e 1 instructions a (Formerly SWRIMST Permit Application Form A and orm hwfwrc-a) Complete this form for all new permits, t or i C roes facility information changes. This form rmrst be submitted within fp2mut facility information changes, unless your local agency requires approval prior to making the changes. For changes, submit only that fang contains the change. Submit one UST Operating Permit Application-Facility Information form per facility,regardless ofthe of USTs 1 at the ty. If not already on file with the local agency,the tank owner must submit with this form,a cormest UST UST;a UST M g Plan and a UST to 23 CCR 2632,2634 and 2641;and,for USTs t Application-Tank ince form for caftficandown of responsibility to 23 CCR 2807. ontaimn �°a ; . The following documents,at a minimum,are alstirequired,if applicable(check with your local agency to see if they require submittal or if themalt other formstinformation needed). O Written agreement between UST Owner and UST Operator per Health and Safety Code§25284(ax3); ® Letter ftam the Chief Financial Officer(ifusing State Cleanup Fund,financial test of self-insurance, tee,local government a test, or Local Goverimicirt Fund as a financial respottsibility ). Pleas numberall pagestifyoursubmittal. (Notr_ Numberingoftlicso instructions matches the data e!ement numbers on the form.) 400. TYPE OF ACTION-Check the mason this form is being submitted. CHECK ONE ITEM ONLY. 404. TOTAL NUMBER OF USTs AT SITE-Indicate the nuniber of tanks that will remain on the site after the requested action. 1. FACILITY ID NUMBER-This space is for agency use only. 3. BUSINESS N the complete Business N (Same as FACIL TY NAME or DBA(Doing Business As)). - 103. BUSINESS SITE ADDRESS-Enter the strect address of the facility,including building number,if applicable.This address must be the physical location of die fatality.Pon office box numbers art not acceptablL 104. CITY-Enter the city or unincorporated area in which the facility is lomted. a 403. FACILITY TYPE-Indicate the type of facility. *, 405. INDIAN RESERVATION OR TRUST LANDS-Check whether the facility is located on an Indian reservation or other trust lands. - 407. PROPERTY OWNER NAME- Complete items 407-412 for the property owner. Include the area code and any i 408. PROPERTY OWNER PHONE- extension number. 409. PROPERTY OWNER MAILING ADDRESS- 410. PROPERTY OWNER CITY- 411. ITY-411. PROPERTY OWNER STATE- 411 PROPERTY OWNER ZIP CODE- j 428-1. TANK OPERATOR NAME- Complete items 428-1 to 428-6 for the UST operator. 428-2. TANK OPERATOR PHONE- Include the code and any extension number. 428-3. TANK OPERATOR MAILING ADDRESS- 4284. TANK OPERATOR CITY- 428-5. TANK OPERATOR STATE- 428-6. TANK OPERATOR ZIP CODE- 414. TANKOWNERNAME- Complete items 414-419 for the UST owner. 415. TANK OW14ER PHONE- Include the area code and any extension number. 416. TANK OWNER MAILING ADDRESS- 417. TANK OWNER CITY- 418. TANK OWNER STATE- 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 applim.to regulated USTs storing petroleum products and is required before your pernift application will 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,PO Box 942879,Sacramento,CA 94279-0030. 423. PERMIT HOLDER INFORMATION-Indicate the party to whom the UST operating permit is to be issued and legal notifications and mailings should be seat. 406. SUPERVISOR OF DMSION SECTION OR OFFICE SUPERVISOR-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 UST records. APPLICANT SIGNATURE-The application form must be signed,in the space provided,by: • The UST owner or operator,facility owner or operator,or a duly audwrized representative of the owner,or • If the UST(s)istare owned by a corporation,partuatship,or public agency: 1.) A principal executive officer at the level of vi 'drat or by an authorized representative responsible for the overall operation of the facility where the UST(s)idare l or 2.) A general par=or proprietor,or 3.) A principal executive office,ranking elected official,or authorized representative of a public agency. 424. DATE-Enter the date the form was signal. 425. PHONE-Enter the phone number of the applicant(i.e., signing the form).Include the area code and any extension number. 426. APPLICANT NAME-Print or type the full name of the pawn signing the form. 427. APPLICANT TITLE-Enter the tide of the parson signing the form. UPCF UST A Rev.(12/2007) ( f