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d UST Operating Permit Application-Facility Information Page 1 Instructions (Formerly SWRCB UST Permit Application Form A and UPCF Form hwfwrc-a) Complete this form for all new permits,permit changes,or 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 the changes. For changes, submit only that form that contains the change. Submit one UST Operating Permit Application-Facility Information form per facility,regardless of the number of USTs located at the facility. If not already on file with the local agency,the tank owner must submit with this form,a current UST Operating Permit Application-Tank Information form for each UST;a UST Monitoring Plan and a UST Response Plan pursuant to 23 CCR 2632,2634 and 2641;and,for USTs containing petroleum,a certification of financial responsibility pursuant to 23 CCR 2807 The following documents,at a minimum,are also required,if applicable(check with your local agency to see if they require submittal or if there are other forms/information needed): U Written agreement between UST Owner and UST Operator per Health and Safety Code§25284(a)(3); O Letter from the Chief Financial Officer(if using State Cleanup Fund,financial test of self-insurance,guarantee,local government financial test, or Local Goverment Fund as a financial responsibility mechanism). Please number all pages of your submittal. (Note: Numbering of these instructions matches the data element numbers on the form.) 400. TYPE OF ACTION-Check the reason this form is being submitted. CHECK ONE ITEM ONLY. 404. TOTAL NUMBER OF USTs AT SITE-Indicate the number of tanks that will remain on the site atter the requested action. 1 FACILITY ID NUMBER-This space is for agency use only 3. BUSINESS NAME-Enter the complete Business Name.(Same as FACILrfY NAME or DBA(Doing Business As)). 103. BUSINESS SITE ADDRESS-Fatter the street address of the facility,including building number,if applicable.This address must be the physical location of the facility.Post office box numbers are not acceptable. 104. CITY-Enter the city or unincorporated area in which the facility is located 403. FACILITY TYPE-Indicate the type of facility. 405. INDIAN RESERVATION OR TRUST LANDS-Check whetherthe 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 408. PROPERTY OWNER PHONE- extension number. 409. PROPERTY OWNER MAILING ADDRESS- 410. PROPERTY OWNER CITY- 411 PROPERTY OWNER STATE- 412. PROPERTY OWNER ZIP CODE- 428-1 TANK OPERATOR NAME- Complete items 428-1 to 428-6 for the UST operator. 428-2.TANK OPERATOR PHONE- Include the area code and any extension number. 428-3. TANK OPERATOR MAILING ADDRESS- 428-4. TANK OPERATOR CITY- 428-5. TANK OPERATOR STATE- 428-6. TANK OPERATOR ZIP CODE- 414. TANK OWNER NAME- Complete items 414-419 for the UST owner. 415. TANK OWNER 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. BOB NUMBER-Enter your State Board of Equalization(BOE)UST storage fee account number. This fee applies to regulated USTs storing petroleum products and is requited before your permit 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, j 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 sent. 406. SUPERVISOR OF DIVISION 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 authorized representative of the owner,or • If the UST(s)is/are owned by a corporation,partnership,or public agency- 1.) A principal executive officer at the level of vice-president or by an authorized representative responsible for the overall operation of the facility where the UST(s)is/are located;or 2.) A general partner or proprietor,or 3.) A principal executive officer,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.,person signing the form).Include the area code and any extension number. 426. APPLICANT NAME-Print or type the Hull name of the person signing the form. 427 APPLICANT TITLE-Enter the title of the person signing the form. UPCF UST A Rev.(12l2Ot17)