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v STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 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 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR g q ' Lk N r'- i -t u L i_ p c_. L_. P.. � 3f i Co X. ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) _ ZIP CODE 94553 PHONE # WITH AREA CODE CITY NAME STATE ZIP CODES TE PHONE # WITH AREA CODE 1V_ CA �!-]-31(r� Zvb- 69000 ✓ Box [X] CORPORATION INDIVIDUAL PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY' Q STATE -AGENCY ° Q FEDERAL -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 INDIAN # OF TANKS AT SITE E.P.A. I. D. # (optional) 0 3 FARM a 4 PROCESSOR a 5 OTHER RESERVATION OR TRUST LANDS N/ EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE If WITH AREA CODE L- WAw ,(L.L...- 39 oo DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE LUevu�O Utas �_ L ��- 6c c`. NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE [I. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME EQUILLON ENTERPRISES LLC CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESSS t/box to indicate INDIVIDUAL LOCAL -AGENCY 0 STATE -AGENCY P.O. BOX 8080 CORPORATION Q PARTNERSHIP COUNTY -AGENCY ® FEDERAL -AGENCY CITY NAME IKARTINEZ, STATE CA ZIP CODE 94553 PHONE # WITH AREA CODE Ill. - (11UST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION EQUILLON ENTERPRISES LLC MAILING OR STREET ADDRESSS ✓ box to indicate INDIVIDUAL LOCAL -AGENCY STATE -AGENCY P.O. BOX 8080 IM CORPORATION 0 PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE MARTINEZ, CA 1 94553 HQ F414] -_a ✓ box to indicate LSU 1 SELF-INSURED M 2 GUARANTEE 0 3 INSURANCE = 4 SURETY BOND Q 5 LETTER OF CREDIT = 6 EXEMPTION = 7 STATE FUND = 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND & CERTIFICATE OF DEPOSIT = 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. ❑ if. ® III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PqtRJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME PRINTED E) ANK OWNER'S TITLE I DATE MONTHIDAYNEAR HS&E REPRESENTATIVE LOCAL AGENCY USE ONLY COUNTY # [J JURISDICTION # FACILITY # m I I I I = LOCATION CODE • OPTIONAL =US TRACT If - 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 INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (6-95)