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pfSn�A�[5 STATE OF CALIFORNIA i STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Sa-lEU_ 4'JIL-i-1Ajj kOVb ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) - -,� - 1'4 NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE , CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE c�I_ti.1t,, r : k �"A �"?int t �-i - ✓ BOX ® CORPORATION 0 INDIVIDUAL = PARTNERSHIP 0 LOCAL -AGENCY COUNTY -AGENCY' STATE-AGENCYFEDERAL-AGENCY' TO INDICATE DISTRICTS R 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 �a 1 GAS STATION 2 DISTRIBUTOR= ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optional) a 3 FARM O 4 PROCESSOR a 5 OTHER RESERVATION OR TRUST LANDS . _ _- N/A EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - oational DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE " 1 ,t = 1 DAYS: NAME (LAST, FIRST) Ai._I-;FT/--,N PHONE # WITH AREA CODE -7i)-,_-,; P.O. BOX 8080 �"", - . � - -,� - 1'4 NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE , NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE �) . WI l L t,i t. i -�'� 'k, - _ -. c�I_ti.1t,, r : k �"A �"?int t �-i - II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME EQUILLON ENTERPRISES LLC CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY (] STATE -AGENCY P.O. BOX 8080 EM CORPORATION PARTNERSHIP COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE MARTINEZ, I CA 94553 I III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER EQUILLON ENTERPRISES LLC CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY P.O. BOX 8080 EM CORPORATION PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE MARTINEZ, CA 94553 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ 4 4 - E a�- V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED ✓ box to indicate I SELF-INSURED = 2 GUARANTEE O 3 INSURANCE 0 4 SURETY BOND = 5 LETTER OF CREDIT = 6 EXEMPTION 0 7 STATE FUND D B STATE FUND 8 CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND 8 CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT. MECHANISM 0 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: 1. ❑ II. III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF /RJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME PRINTED E) ANK OWNER'S TITLE DATE MONTHIDAYNEAR Ail &�TZIATHS&E REPRESENTATIVE -,— LOCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL I 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 THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU -ORAGE TANK REGULATIONS FORM A (6-95)