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#95575 STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ® 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION F-1 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME R.J. McComb Chevron CARE OF ADDRESS INFORMATION.-, . i'. 71—� "_1 -,LI Chevron USA, Inc. MAILING or STREET ADDRESS 100 West Pine Street ^ 17 t ADDRESS NEAREST CROSS STREET ✓ 600z lw5 i rale ' PARTNERSHIP Cl STATE -AGENCY 301 West Kettleman Lane Hutchins ❑ CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY 95240 ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME Lodi STATE ZIP CODE 95420 SITE PHONE #, WITH AREA CODE 209-368-8614 DATE FILED CA PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOI ✓ Box it INDIAN EPA ID #ESE X❑ 1 GAS STATION [:]3 FARM ❑ 5 OTHER TRUSTVLANDS ATION or ❑ # of TANK': AT THIS SITE 4 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE McComb, R.J. 209-368-8614 Barber, Bob 209-368-8614 NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE McComb, R.J. 209-368-8757 Barber, Bob 209-368-3281 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Mrs. Angiolina Chevron USA, Inc. MAILING or STREET ADDRESS 100 West Pine Street ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY ElCORPORATION 11LOCAL-AGENCY❑ FEDERAL -AGENCY ® INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE Lodi CA 95240 PHONE #, WITH AREA CODE III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION AGENCY # Chevron USA, Inc. # of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID # MAILING or STREET ADDRESS P.O. Box 5004 ✓ Box to indicate 29 CORPORATION ❑ INDIVIDUAL ❑ PARTNERSHIP ❑ STATE -AGENCY ClLOCAL-AGENCY ClFEDERAL-AGENCY ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE San Ramon CA SUPERVISOR -DISTRICT CODE 94583 415-842-9050 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ 111. THIS FORM HAS BEEN COMPLETED UNDER PENH ERJURY D 01117E" OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRINTED & SIGNATURE) DATE -Pkl� c- TO msv.,i I nCAL AGENCY USE ONLY COUNTY # m JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE CURRENT LOCAL AGENCY FACILITY ID # APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT # SUPERVISOR -DISTRICT CODE BUSINESS PLAN FILED YES NO ❑ DATE FILED CHECK # PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) 0° YORE TANK PERMIT FORM °B' APPLICATION(S), UNLESS TFMIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A (3-2-88) DATA PROCESSING COPY .p