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_ UgCCS STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A as COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® 7 PERMANENTLY C SED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE �i I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR CHEVRON SERVICE STATION ROBERT MCCOMB ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) 301 W. KETTLEMAN LANE PLEASANT AVENUE 045-140-02 CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE LODI CA 95240 (209)368-8614 ✓ BOX f CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY' Q STATE -AGENCY' Q FEDERAL -AGENCY' TO INDICATE DISTRICTS If 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 ,�j 1 GAS STATION a 2 DISTRIBUTOR= ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. # (optional) X� Q 3 FARM Q 4 PROCESSOR Q 5 OTHER RESERVATION OR TRUST LANDS 5 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE WALLACE, LARRY 925-842-9083 DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE MUSCO. BRYAN 707-579-0250 NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME IVERN RAFFONI, ETAL CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY 1 1 7 5 ORANGEWOOD DRIVE Q CORPORATION PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE LODI CA 95240 STATE ZIP CODE III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CHEVRON USA CARE OF ADDRESS INFORMATION DATE MONTH/DAY/YEAR W. IN44Co- —� BRYAN H. f1US MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY PO BOX 5004 ® CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE SAN RAMON I CA 94583 925-842-9083 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ 44- -1 0 1 93� V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE Q 4 SURETY BOND Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 7 STATE FUND Q 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND & CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT. MECHANISM Q 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. ❑ II. ❑ III. L THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT TANK OWNER'S NAME (PRI TED,&�,Sf GNATURE) TANK OWNER'S TITLE DATE MONTH/DAY/YEAR W. IN44Co- —� BRYAN H. f1US 0 FOR CHEVRON USA 7/13/98 LOCALAGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # J ❑ LOCATION CODE -OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL v 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 FOR 1i THE LOCAL AGENCY IMPLEMENTING THE UNDERGR/ STORAGE TANK REGULATIONS FORM A (6-95)