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ou"cue STATE OF CALIFORNIA :r'�,•��" cO, STATE WATER RESOURCES CONTROL BOARD dam, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE '� l IVEW Devi_ oPerw-ror �/c /f9 MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SI 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 / ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL)? 7 00 /�orc la.. .� �Q� c Hwy 9 9 CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE STockTort CA 9 S L/ Z Zoo 9s 1 S398 ✓BOX Q CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY• 0 STATE-AGENCYFEDERAL-AGENCY• TO INDICATE DISTRICTS N 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 1 GAS STATION ❑ 2 DISTRIBUTOR O ✓IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION O 3 FARM a 4 PROCESSOR = 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAY : NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE If WITH AREA CODE 42/4L, fya/a," zo? 9s 1 S3 98 A 19/c CAA .- Logy 4.S> S mr NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGH1t: NAM (LAST,FIRST)# PHONE#WITH AREA CODE • S10 ;77z. 31ST '• 1. S-/o 77Z 3/sl II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION EQUILON ENTERPRISES LLC PERMIT ANALYST — B.T. MARUBASHI MAILING ORS EET ADDRESS ✓ box to ndicate l� INDIVIDUAL LOCAL-AGENCY Q STATE-AGENCY C�0 P.O. BOX 8509 g CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE SAN JOSE CA 95155 408-269-6156 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION SAME AS II MAILING OR STREET ADDRESS ✓ boxto indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY =CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ 4 4- - 0 1319 1-b-M 6 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 11 4 SURETY BOND Q 5 LETTER OF CREDIT 0 6 EXEMPTION =7 STATE FUND (]8 STATE FUND d CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND 8 CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT.MECHANISM = 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. 11.❑ "'.=71 THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTH/DAYNEAR Bruce T. Marubashi for EE LLC �l PERMIT ANALYST LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY It LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIOW ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A(6-95)