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STATE OF CALIFORNIA .° STATE WATER RESOURCES CONTROL BOARD W UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY a OCFn sITF _ ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSUREl7' �- I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) r)RA OR FACILITY NAME NAME OF OPERATOR Dalbiy- ADDMS8 NEAREST CROSS STREET PARCEL#(OPTIONAL) CIN NAME �Q STATE ZIP CODE SITE PHONE#WITH AREA CODE 7 vYv CA V BOX TOINDICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY' Q FEDERAL-AGENCY' DISTRICTS' If owner of UST is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS K t GAS STATION Q 2 DISTRIBUTOR RESERVATIONIF INDAN #OF TANKS AT SITE E.P.A. I.D.#(optional) Q FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE CO LETED NAME CARE OF ADDRESS INFORMAT1 71 MAILING OR STREET ADDRESS ✓ box b indicate Q Q INDLOCAL-AGENCY TSTATE-AGENCY CORPORATION NERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY i CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 111. TANK OWNER INFORMATION•(MLIdT BE COMPLETED) NAME OF OWNER CARE OF ADD111 INFORMATION MAILING OR STREET ADDRESS ✓ box bindic Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY Q CORPO TION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZA ON UST STORAGE FEE ACCOUNT NUMBE -Call(916)322-9669 if questions arise. TY(TK) HQ M44- - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE C PLETED)—IDENTIFY THE METHOD(S) USED ✓ box bindicate Q 1 SELF-INSURED 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= if.= 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTWDAYIYEAR LOCAL AGENCY USE ONLY -T D a 3 67 COUNTY# JURI�SDIC(TIIOON# FACILITY# &YLJ�J LOCATION COD -OPTIONAL CENSUS TRA # -OPTIONAL SUPVISOR-DISTRICTOPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIM FORMA(3193) FOR0033A•1117