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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE 'n ' MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CL ONE IT ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PEPMIT O e TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA O FACILITY NAME N OF OPERATOR . hevron S+c,+ Ion *� 90�57 onola P SGnchcx- I ADDRESS NEAREST CROSS STREET PARCELe(OPTIONAL) 139 So. � ,-n+Cl Wnshv? ion 54. CITY NAME STATE ZIP CODE SITE PHONE M WITH AREA CODE S4oc k �on CA 95,,?oa, a03-461- 16-25 I ✓BOX Q CORPORATION O INDIVIDUAL 0 PARTNERSHIP ED LOCAL-AGENCY O COUNTY-AGENCY' STATE-AGENCY- O FEDERAL-AGENCY' TO INDICATE DISTRICTS I mer of UST 3 a public ager/,=nPNb the lobw'H6 none of sWe r of ONbbn,seuion or offm Al operates the UST TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR RESERINDIIOAN N x OF TANKS AT SITE E P.A. I.D.N(Cplm"O 3FARM Q < PROCESSOR Q 5 OTHER OR TRUST LANDS 9 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE Jr WITH AREA CODE DAYS: NAME(LAST, ST) PHONE I WITH AREA CODE S r: 2.6q-y41= zr" Chevron aIn+enanee- 352,8 NIGHTS: NAME(LAST.FIRST) PHONE I WITH AREA CODE NIGHTS NAME(LAST,FIRST) ' f PHONE R WITH AREA CODE i N t - 51-75; Chwrvn Emer rr STTtpYmc9{1un 800-a31-0623 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION rr hound 'nes Inc. MAILING ORTREE! x TT�N9ADDRESS ��✓ babnGal° INDIVIDUALAL Q LOCAL-AGENCY f�SrATE-AGENCY PI)- 13 V 8 I I O (Y OORPORATION O PARTNERSHIP 0 COUNTY-AGENCY Fmr4UL-AGENCY CITY NAMESTATE LP CODE PHONE 0 WITH AREA CODE I_o« I<-. v ; 'lI - K 46298 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) N EOFOWNEFI - C OF ADDRES IN MAT h t' 'I ,A s Dom un1 rrnl s MAIyNG OR STR ADDRES�UO,{ �✓yboxb�e � NDMWAL LOCAL-AGENCY ED STATE-AGENCY I(J V 1 `i C CORPORAT)ON =PARTNERSHIP COUNTY-AGENCY O FEDERAL-AGENCY CITY NAME STATE ZIP COOF PHONE I WITH AREA CODE Son Rom6n 0A ojq550f0-8 - -C)U0.2. IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HO 44- - 0 3 1 9 1 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓be to iMiealeEj-e6 SELF-INSURED O 2 GUARANTEE 0 3 INSURANCE O A SURETYBOND E=j 5 LLTTEROFCRED1r =a EXEMFr10N 0 7 STATE FUND =0 STATE FUND&CHIEF FINANCIAL OFFICER LETTER [:19 STATE RIND&CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT.MECHANISM O W 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: L❑ 11.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUEAND CORRECT TANK OWNERS NAME(PRINTED&SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAWYEAR CUoti �te14 lrnk Assf Y.» tL-s.L a1 19 � LOCAL AGENCY USE ONLY COUNTY N JURISDICTION p FACILITY M LOCATION CODE-OP7IONAL CENSUS TRACT 0 -OP77ONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT T(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS- i IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM. H THE LOCAL AGENCY IMPLEMENTING THE UNDERGROL_.-iTORAGE TANK REGULATIONS FORM A(6-95)