UNIFIED PROGRAM CONSOLIDATED FORM

UNIFIED PROGRAM CONSOLIDATED FORM
TANKS
UNDERGROUND STORAGE TANKS - FACILITY
(one page per site)
TYPE OF ACTION
(Check one item only)
1. NEW SITE PERMIT
3. RENEWAL PERMIT
4. AMENDED PERMIT
5.CHANGE OF INFORMATION
specify change local use only
Page ____ of ____
7.PERMANENTLY CLOSED SITE
8. TANK REMOVED
6.TEMPORARY SITE CLOSURE
400
I. FACILITY / SITE INFORMATION
BUSINESS NAME (Same as FACILITY NAME or DBA – Doing Business As)
3
FACILITY ID#
1
NEAREST CROSS STREET
BUSINESS
TYPE
401
1. GAS STATION
2. DISTRIBUTOR
3. FARM
4. PROCESSOR
TOTAL NUMBER OF TANKS
REMAINING AT SITE
5. COMMERCIAL
6. OTHER
403
Yes
No
4. LOCAL AGENCY/DISTRICT*
5. COUNTY AGENCY*
2. INDIVIDUAL
3. PARTNERSHIP
6. STATE AGENCY*
7. FEDERAL AGENCY*
402
*If owner of UST is a public agency: name of supervisor of division, section or office which
operates the UST (This is the contact person for the tank records.)
Is facility on Indian Reservation or
trustlands?
404
FACILITY OWNER TYPE
1. CORPORATION
405
406
II. PROPERTY OWNER INFORMATION
407
PROPERTY OWNER NAME
PHONE
408
MAILING OR STREET ADDRESS
409
410
CITY
PROPERTY OWNER TYPE
1. CORPORATION
411
STATE
ZIP CODE
412
2. INDIVIDUAL
4. LOCAL AGENCY / DISTRICT
6. STATE AGENCY
3. PARTNERSHIP
5. COUNTY AGENCY
7. FEDERAL AGENCY
413
III. TANK OWNER INFORMATION
TANK OWNER NAME
414
PHONE
415
416
MAILING OR STREET ADDRESS
CITY
417
TANK OWNER TYPE
1. CORPORATION
STATE
418
ZIP CODE
419
2. INDIVIDUAL
4. LOCAL AGENCY / DISTRICT
6. STATE AGENCY
3. PARTNERSHIP
5. COUNTY AGENCY
7. FEDERAL AGENCY
420
IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER
TY (TK) HQ 44-
Call (916) 322-9669 if questions arise
421
V. PETROLEUM UST FINANCIAL RESPONSIBILITY
INDICATE METHOD(s)
1. SELF-INSURED
2. GUARANTEE
3. INSURANCE
4. SURETY BOND
5. LETTER OF CREDIT
6. EXEMPTION
7. STATE FUND
8. STATE FUND & CFO LETTER
9. STATE FUND & CD
10. LOCAL GOVT MECHANISM
99. OTHER:
422
VI. LEGAL NOTIFICATION AND MAILING ADDRESS
Check one box to indicate which address should be used for legal notifications and mailing.
Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked.
1. FACILITY
2. PROPERTY OWNER
3. TANK OWNER
423
VII. APPLICANT SIGNATURE
Certification – I certify that the information provided herein is true and accurate to the best of my knowledge.
SIGNATURE OF APPLICANT
DATE
424
PHONE
425
NAME OF APPLICANT (print)
426
TITLE OF APPLICANT
427
STATE UST FACILITY NUMBER (For local use only)
428
1998 UPGRADE CERTIFICATE NUMBER (For local use only)
429
UPCF (1/99 revised)
Formerly SWRCB Form A
UST - Facility
Formerly SWRCB Form A.
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
showing the location of the USTs with respect to buildings and landmarks [23 CCR ∋2711 (a)(8)], a description of the tank and piping leak detection
monitoring program [23 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 name of the supervisor for the division, section or office
which 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
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
notifications and mailings will be sent to the tank owner unless the facility (box 1) or the property owner (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)
Formerly SWRCB Form A