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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> off" <br /> C PLETETHIS FORM FOR EACH FACILTTYISITE <br /> MARK ONLY Q 1 NEW PERMIT RENEWAL PERMIT ® 5 CHANGE OF INFORMATION 7 PERMANENTLY CL :9, <br /> ONE ITEM C 2 INTERIM PERMIT 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATO <br /> Ck",roA 4 O Ss-7 0 . 4nA4 t^ez <br /> ADDRESS )•3 1 �. ♦✓Q,{�7L QAC NEAREST CROSS STREET PARCELS(OPTIONAL) <br /> CITY NAME 1 STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA 4SZoZ ZZl+4 - �b? - bz� <br /> t TI/ BOX O CORPORATION >0 INDIVIDUAL 0 PARTNERSHIP LDCAL-AGENCY D COUNTY-AGENCY 0 STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS �I 1 GAS STATION 2 DISTRIBUTOR E=1 <br /> ,/ IF INDIAN N OF TANKS AT SITE E.P.A. 1.D.;1(CpHonal) <br /> RESERVATION Zqb T 3 <br /> O 3 FARM O 4 PROCESSOR 05 OTHER OR TRUST LANDS CAL,0000 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) z q - ` 6.7 - I b aS <br /> Sow[Ititz r Ui - 4b? - fbzS 5a i� }ov So¢ <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4WITH AREA CODE NIGHTS. AME( AST,FIRST) Za`l - 957 - 7568 <br /> Sov-A��z how Zoq-9S1 - DE Toe pwnmp.WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NCHEVRON USA PRODUCTS CO. CARE OFADDRESS INFORMATION <br /> MAILING OR STREET ADDRESS ✓ boa bMk#e O INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> P.O. BOX 5004 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY ED FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE t611H AREA 00 <br /> SAN RAMON CA 94583 ( 51U ) 84T-e9500 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF AD INFORMATION <br /> CHEVRON USA PRODUCTS CO. <br /> MAILING OR STREET ADDRESS- As✓ bmbindmW INDIVIDUAL OLOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 5004 X-,1 CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SAN RAMON CA 94583 ( 510 ) 842-9500 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 -n 3 1 9 1 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box 0 micaleXL 1 I SELF-INSURED [::12 GUARANTEE 0 3 INSURANCE [71 4 SURETY SONO <br /> 5 LETFEROFCREDT 0 6 EXEMPTION 0 99 OTHER <br /> 71 <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.F] 11.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED A SIGNATURE) APPLICANTS TITLE DATE MONTWDAY/YEAR <br /> KATHY NORRIS }�A)OIVIs MKTG ASST 4f - /6 - 73 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 39 fp- 1 <br /> LOCATION CODE OPTIONAL CENSUS TRACTZA -OPTION L SUPVISOR-D TRIC C E -OPTIONAL <br /> In iia Z <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION 9NLY. <br /> FORM A(12-9n FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> - AA6 <br />