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WdL^r4.IM DVd Ii "A As d'ad'a LTQnT Y59 A rr'ri-A R' its TANKS f NUNDERGROUND STORAGE TANKS - FAcILLITY (one page per site) Page_of TYPE OF ACTION ® 1.NEW SITS PERMTf ❑3.RENEWAL PERMIT ER 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ S.TANK REMOVED ❑&TEMPORARY SITE CLOSURE 400 I. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Buame s As) 3 FACILITY ID SBC Services#ESCLCAI I -- 1 NEAREST CROSS STREET 401 FACILITY OWNER TYPE [14.LOCAL GENCY/DISTRICT* Second St. ® 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS ❑1.GAS STATION [13.FARM [15. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR®6. OTHER 4o3 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 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 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 419 SBC Services (800)757-6575 MAILING OR STREET ADDRESS 409 2600 Camino Ramon,Rm. 3E000 CITY 410 STATE 411 ZIP CODE 412 San Ramon I CA 1 94583 PROPERTY OWNER TYPE CgLCORPORATION ❑2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 IIL 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 1 STATE 419 ZIP CODE 419 San Ranson CA 94583 TANK OWNER TYPE ®1.CORPORATION [12.INDIVIDUAL ❑4.LOCAL AGENCY!DISTRICT [16.STATE AGENCY 420 ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 3 1 1 91. 4 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ®1.SELF-INSURED [:14.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑S.STATE FUND&CFO LETTER ❑ 99.OTHER: ❑3.INSURANCE ❑6.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.FACII TfY ❑2. PROPERTY OWNER ®3.TANK OWNER 423 VI$.APPLICANT SIGNATURE Certifwati -I certify that the information provided herein is true and accurate to the best ofmy knowledge. SIGNA OF A LIC. DATE 420 PKONE 425 10/16/03 (916)635-2444 NAW OF APPLICANT(pin 426 TITLE OF APPLICANT 427 Anly C.ley Agent for Owner STATE UST FACILITY NUMBER(For localuse oniy) 428 1998 UPGRADE CERTIFICATE NUMBER(For tacatuseonly) 429 1 l-P(',l-' 0 MC)rnvigndC 171 FnrmPr1v,R'WRCR Fnrrn A