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From 11/03/2008 15°35 #164 P 015/033 UPCF UST Operating Permit Application—Facility Information Page 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 trust be submitted within 30 days of perrnit or facility information changes, unless your local agency requires approval prior to making the changes. For changes, submit only that fothat contains the change. rm 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 Inforrttation 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): 0 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 Government 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 after the requested action. I FACILITY ID NUMBER-This space is for agency use only. 3. BUSINESS NAME-Enter the complete Business Name.(Same as FACILITY NAME or DBA(Doing Business As)). 103. BUSINESS SITE ADDRESS--Enter 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 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 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 BOE NUMBER- Enter your State Board of Equalization (BOE) UST storage fee account number This fee applies to regulated USTs storing petroleum products and is required 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, 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: L) 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 signed. 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 full name of the person signing the form. 427 APPLICANT TITLE-Enter the title of the person signing the form. UPCF UST-A Rev.(t 2(2007)-212 www.,anidoes.org