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a 'n'DiDnrD A its iY1NQ1%T Inn A rrv">c <br /> TANKS <br /> Cil UNDERGROUND STORAGE TANK - F CIL <br /> v <br /> (d 1� d (ane p per site) Page <br /> TYPE OF ACTION ® I.NEW SITE PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7YERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ® S.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> L FACILITY/SITE INFORMATION O Z 1 j <br /> BUSINESS NAME(Same as FACILITY NAME or DHA-Doing Business As) 3 FACILITY ID# A _ D Q 11-11 <br /> I <br /> SBC Services#ESCLCA11 <br /> 10 I <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> Second St. ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR®6. OTHER 4o3 ❑ 3.PARTNERSHIP [17.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Ifowner ofUST is a public agency:name of supervisor of division.section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 0 404 ❑ Yes ® No 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> SBC Services (800)757-6575 <br /> MAILING OR STREET ADDRESS 409 <br /> 2600 Camino Ramon,Rm.3E000 <br /> CITY 410 STATE 411 ZIP CODE ate <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE O L CORPORATION 02-INDIVIDUAL 4.LOCAL AGENCY 1 DISTRICT ❑6.STATE AGENCY <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY 413 <br /> IM TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> SBC SeMceS (800)757-6575 <br /> 416 <br /> MAILING OR STREET ADDRESS <br /> 2600 Camino Ramon Rm 3E000 <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE ®1.CORPORATION 0 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> [13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 3 11 19 1 1 14 1 Call(916)322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE [16.EXEMPTION ❑9.STATE FUND&CD s22 <br /> VL LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2.PROPERTY OWNER ®3.TANK OWNER 423 <br /> VIL APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATM OF APPLICANT DATE 424 1 PHONE 425 <br /> 10/16/03 (916)635-2444 <br /> N OF PLICANT(print 426 TITLE OF APPLICANT 427 <br /> Amy C.Dy Agent for Owner <br /> STATE UST FACILITY NUMBER(For tow use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local..*) 429 <br /> 1 <br /> TTPCF(1/99 re."w-.d) 171 Fnrmerly CWRCR Form A <br />