Cal. Code Regs. Tit. 18, div. 2, ch. 1.5, art. 1, exh. A - Statement of Underground Storage Tank Owner

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

Notes

Cal. Code Regs. Tit. 18, div. 2, ch. 1.5, art. 1, exh. A