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0 0 <br /> STATE OF CALIFORNIA ...... <br /> STATE WATER RESOURCES CONTROL BOARD 0 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION F__] 7 PERMANENTLY CLOSED,SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> C ly <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> G <br /> CA <br /> V BOX CORPORATION O INDIVIDUAL a PARTNERSHIP LOCAL-AGENCY a COUNTY-AGENCY' a STATE-AGENCY FEDERAL-AGENCY <br /> TO INDICATE DISTRICTS <br /> 9 owner of UST is a public agency,complete the following name of sLipervisor of division,section or office,which operates the UST <br /> TYPE OF BUSINESS XX 1 GAS STATION a 2 DISTRIBUTOR V IF INDIAN 1#OF TANKS AT SITE E.P.A. 1.D.#(optional) <br /> RESERVATION I q <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS I N/A <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 6 0 E__14 Ev 14\I'_PW (2,Dg) -9 1 S 6 -BILL, E16co) Lfq��_�61SS_2_ <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> EQUILLON ENTERPRISES LLC <br /> MAILING OR STREET ADDRESS V box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 8080 CM CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> MARTINEZ , CA 94553 <br /> Ill. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> EQUILLON ENTERPRISES LLC <br /> MAILING OR STREET ADDRESS V boxtoindicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 8080 [M CORPORATION O PARTNERSHIP a COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> MARTINEZ , CA � 94553 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO F4-f4--]- 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> I SELF-INSURED =2 GUARANTEE =31NSURANCE 0 4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION F-1 7 STATE FUND <br /> 8 STATE FUND CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 99 OTHER <br /> V1. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OFRJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> TANK OWNER'S / <br /> NAME PRINT ANK OWNER'S TITLE DATE MONTWDAYNEAR <br /> HS&E REPRESENTATIVE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# V FACILITY# <br /> FTTI I I I I I I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LI&T(1)OR MORE PERMIT APPLICATION- FORM 8,UNLESS Ak IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(6-95) OWNER MUST FILE THIS FORM W THE LOCAL AGENCY IMPLEMENTING THE UNDERGROLAWORAGE TANK REGULATIONS <br />