Cal. Code Regs. Tit. 18, div. 2, ch. 1.5, art. 1, exh. A - Statement of Underground Storage Tank Owner
Exhibit A
STATEMENT OF
(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
___________________________ | ||
Location of tanks(s) STREET | CITY | COUNTY |
___________________________ | ||
Name of Tank |
Area Code and Phone Number | |
___________________________ | ||
Mailing Address of Tank
|
By executing this document, I/we understand that all
returns and notices regarding the above
___________________________ | ___________________________ | ||
Name of Tank |
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 |
Notes
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