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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD u dam, o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT -5 CHANGE OF INFORMATION ❑ T PERMANENTLY CLOSE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT n 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR p1'F--ipO12-C -540-j— D. 1�I O I L- I W C . ADDRESS NEARESTCROSS STREET PARCEL#(op RONAL) 13th F-- "AAT-'T-CV-- WAS; CITY NAME STATE ZIP CODE SITE PHONE R WITH AREA CODE StDC-I TDN CA RSZoS (709 944-43tS ✓BOX ®CORPORATION 0 INDIVIDUAL O PARTNERSHIP O LOCA-AGENCY O COUNTY-AGENCY' O STATE-AGEICY• O FEDFR&-AGENCY' TO INDICATE DISTRICTS 'Mowmrd USTb apubGo agrcy,mogRta Netobwnl7 name d supsrviwrd&+aim,section waft whkh ops the UST TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓IF INDIAN #OFSITE E P.A. I.D.M(optional) RESERVATION ❑ 3 FARM ❑ 4 PROCESSOR ❑ 5 OTHER OR TRUST LANDS K N/A 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 all IM�1 DP 709 Nps-I`lW UoYA�, e(ztSt�A" (Sit)) 293-91SO NIGHTS: NAME(LAST,FIRST) PH NE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITHAREACODE Il 1NELDA (2D9) 41'S-13 }�U 6u0 ollvt k-�iSIAAW (Slo)'-4q$- OlZb If. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION EQUILLON ENTERPRISES LLC MAILING OR STREET ADDRESS y✓,boaMRbme OINDIVIDUAL ED LOCAL-AGENCY OSTATE-AGENCY P.O. BOX 8080 lm CORPORATION E::] PARTNERSHIP O COUNTY-AGENCY E:3 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE 0 WITH AREA CODE MARTINEZ , CA 94553 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION EQUILLON ENTERPRISES LLC MAIUNG OR STREET ADDRESS p ✓ bo41o#Mi®te 0 INDNIOUAL D LOCAL-AGENCY STATE AGENCY P.O. BOR OOOO CORPORATION Q PARTNERSHIP O COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE MARTINEZ , CA 1 94553 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ R:4 - V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓bos MiM�K I� 1 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE O 4 SURETY BOND Q 5 LETrEROFCREDR O 6 EXEMPTION O T STATE FUND Q e STATE RIND A CHIEF FINANCIAL OFFICER LETTER 119 STATE FUND&CERTIFICATE OF DEPOSIT l= 10 LOCAL GOVT.MECHANISM O99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or It is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.® III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNERS NAME PRINTED E) ANK OWNERS TITLEDATE MONTHVDAY/YEAR Wb L HSEE REPRESENTATIVE —� LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# D03705 m 3 /1 U 'f 9 LOCATIONCODE -OPTIONAL CENSUS TRACT# -OPDONA SUPVISOR-DISTRICT CODE -OPTIONAL A THIS FORM MUST BE ACCOMPANIED BY AT LF.,A°T(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS THIS,IS A CHANGE OF SITE INFORMATION ONLY. FORMA(6-95) OWNER MUST FILE THIS FORM�..ME LOCAL AGENCY IMPLEMENTING THE UNDERGROUt�ORAGE TANK REGULATIONS