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s , TANKS UNDERGROUND STORAGE TANKS - FACILYff (one page per site) Page-of TYPE OF ACTION ® I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ER 5.CHANGE OF INFORMATION ❑ 7YERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ S.TANK REMOVED ❑6.TmeoRARY SITE CLOSURE 400 L FACILITY/SITE INFORMATION BUSINESS NAME(same asFAMMYNAME orDBA-DoiogBusiness AS) 3 FACILITYID# SBC Services#ESCLCAl l NEAREST CROSS STREET 401 FACILITY OWNER TYPE T4.LOCAL GENCY/DISTRICT* Second St ® 1.CORPORATION ❑5.COUNTYAGENCY* BUSINESS ❑1.GAS STATION ❑3.FARM 0 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR N 6. OTHER 4o3 ® 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Mowner ofUST is a public agency:name ofsupervisor of division,section or office which REMAINING AT SITE trustlands? operates the UST('This is the contact person for the tank records.) 1 404 ❑ Yes ® No 405 406 IL PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 SBC Services (800)757-6575 MAILING OR STREET ADDRESS 40 2600 Camino Ramon,Rm.3E000 CITY 410 1 STATE 411 ZIP CODE 412 San Ramon CA 94583 PROPERTY OWNER TYPE MI.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY [13.PARTNERS ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 Id TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 SBC Services (800)757.6575 MAILING OR STREET ADDRESS 416 2600 Camino Ramon Rm 3E000 CITY 417 STATE 418 ZIP CODE 419 San Ramon CA 94583 TANK OWNER TYPE ®1.CORPORATION ❑2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 ❑3.PARTNERSHIP ®5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF]EQUA 17ATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 3 1 1 19ITT-47- Cafl(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) 01.SELF-INSURED 0 4.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM [12.GUARANTEE [15.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑ 99. R: ❑3.INSURANCE [16.EXEMPTION ®9.STATE FUND&CD 422 VL LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423 VII.APPLICANT SIGNATUM Certi£cati -I certify that the infomtation provided herein is tree and accurate to the best ofmy knowledge. SIGNA OF AP LIC DATE 42a PHOS 425 10/16/03 (916)635-2444 NAW OF APPLICANT(prin 426 TITLE OF APPLICANT 427 Amy C.Dy Agent for Owner STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For iocat use only) 429 I TP(F(1/()9 rnvigedl 171 FiirmE-.rlv CVkfRR:R Farm A