Laserfiche WebLink
79 DiDnf 4ip A its P1r4hTCf%T rn A Ir "1ST <br /> UNDERGROUND STORAGE TANKS <br /> TANKS <br /> ANT - FAQ <br /> (one page per site) Page,of <br /> TYPE OF ACTION ® 1.NEW SITE PERMrr ❑3.RENEWAL PERMrf ®S.CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED STfE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ® S.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE ® TION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> 1 <br /> SBC Services#ESCLCA11 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE El 4.LOCAL GENCYIDISTRICT <br /> Second St. 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ❑1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR 0.4.PROCESSOR®6. OTHER 4o3 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner ofUST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(chis is the contact person for the tank records.) <br /> 0 404 ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE as <br /> SBC Services (800)757-6575 <br /> MAILING OR STREET ADDRESS 40 <br /> 2600 Camino Ramon,Rm.3E000 <br /> CITY 41, STATE au I ZIP CODE 412 <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE 0 1.CORPORATION 1:12-INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> [13.PARTNERS ❑5.COUNTY AGENCY [17.FEDERAL AGENCY 413 <br /> ja TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> SBC Services (800)757-6575 <br /> 416 <br /> MAILING OR STREET ADDRESS <br /> 2600 Camino Ramon Rm 3E000 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> San Ramon CA 1 94583 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> [13.PARTNERS ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 3 1 9 1 14 1 Call(916)322-9669 if estions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4_SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILWG ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing <br /> Legal notifications and mailings wall be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER IN 3.TANK OWNER 423 <br /> VIEL APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATOE OF APPLIC DATE 42a PHONE 425 <br /> 10/16/03 (916)635-2444 <br /> N OF PLICANT(prnrt) 426 TITLE OF APPLICANT 427 <br /> Amy C.1)y Agent for Owner <br /> STATE UST FACILITY NUMBER(For 1oca1 use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For IoCeluse onty) 429 <br /> T TP(`F(1/99 rm i reed) 171 Fnrmeriv SWR CR Fnrm A <br />