ALAMEDA COUNTY DEPARTMENT OF ENVIRONMENTAL …
|ALAMEDA COUNTY DEPARTMENT OF ENVIRONMENTAL HEALTH |
| |
|CHANGE OF OWNERSHIP/OPERATOR |
|FOR UNDERGROUND STORAGE TANKS |
| |
|Instructions |
|Please type or print in ink all items except the “Signature of New UST Owner/Operator” in Section V. This form must be completed and submitted within 30 days of |
|acquiring ownership/operator of a UST. The new owner’s/operator’s signature is required in Section V for this form to be valid. |
|I. Facility Information |II. Ownership/Operator of UST(s) |
|Ownership/Operator Transfer Date: |New Owner’s/Operator’s Name: |
| | |
|_____________________________________________________ |_____________________________________________________ |
| | |
|Previous Owner’s/Operator’s Name: |Mailing Address: ______________________________________ |
| | |
|_____________________________________________________ |_____________________________________________________ |
| | |
|Address: ____________________________________________ |_____________________________________________________ |
| | |
|_____________________________________________________ |Phone Number: (_____)_______________________________ |
| | |
|Phone Number: (_____)______________________________ |Fax Number: (_____)_________________________________ |
| | |
| |Email: ______________________________________________ |
|III. Location of Tank(s) |IV. Items to Complete for Permit Transfer |
|Facility Name: | |
| |Underground Storage Tanks – Facility Form |
|_____________________________________________________ | |
| |Owner Statement/Assignment of Designated Operator |
|Address: ____________________________________________ | |
| |Owner/Operator Agreement (If operator is not owner) |
|_____________________________________________________ | |
| |Certification of Financial Responsibility |
|_____________________________________________________ | |
| |Underground Storage Tank Monitoring Plan |
|Phone Number: (_____)______________________________ | |
| |Underground Storage Tank Response Plan |
|Contact Person: _______________________________________ | |
| |Hazardous Materials Business Plan (HMBP) |
|V. Certification (Read and sign after completing all sections.) |
|I certify under penalty of law that I have personally examined and am familiar with the information submitted in this document, and that based on my inquiry of |
|those individuals immediately responsible for obtaining the information, I believe that the submitted information is true, accurate, and complete. |
|Name and Official Title of New UST Owner/Operator (print) |Signature of New UST Owner/Operator |Date |
| | | |
|Return this completed form to: |
|Alameda County Department of Environmental Health HazMat CUPA , 1131 Harbor Bay Pkwy, Alameda, CA 94502 |
|Phone (510) 567-6700 Fax (510) 337-9335 |
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