Cal. Code Regs. Tit. 18, div. 2, ch. 1.5, art. 1, exh. A
Exhibit A
STATEMENT OF UNDERGROUND STORAGE TANK OWNER
(Title 18, California Code of Regulations, Section 1213)
Account No.: TK MT 44-______________________________
I hereby authorize the Board of Equalization to send all notices and returns concerning the identified Underground Storage Tank Maintenance Fee (Part 26, Division 2 of the Revenue and Taxation Code, commencing with Section 50101) Account to the following:
| ___________________________ | ||
| Location of tanks(s) STREET | CITY | COUNTY |
| ___________________________ | ||
| Name of Tank Operator | Area Code and Phone Number | |
| ___________________________ | ||
| Mailing Address of Tank Operator |
By executing this document, I/we understand that all returns and notices regarding the above Underground Storage Tank Maintenance Fee Account will be mailed to the tank operator identified above, but that I/we am/are responsible for payment of all Underground Storage Tank Maintenance Fees, penalties and interest due based on the gallons of petroleum placed in the underground storage tank(s). I/we also acknowledge receipt of a copy of the Board's Publication 88, Underground Storage Tank Fee.
| ___________________________ | ___________________________ | ||
| Name of Tank Operator (Please Print) | Area Code and Telephone Number | ||
| ___________________________ | |||
| Mailing Address of Tank Owner | |||
| ___________________________ | ___________________________ | ||
| Signature of Tank Owner | Date | ||
| ___________________________ | |||
| Title (owner, partner, corporate officer) | |||
| ___________________________ | ___________________________ | ||
| Signature of Tank Owner | Date | ||
| ___________________________ | |||
| Title (owner, partner, corporate officer) | |||
| Attach Notary Statement Here |
Cal. Code Regs. Tit. 18, div. 2, ch. 1.5, art. 1, exh. A