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#90557 _ <br /> STATE OF CALIFORN'hk WATER RESOURCES CONTROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH F ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑X 3RENEWAL PERMIT 5 CHANGE OF INFORMATION Skb SITE O <br /> ONE ITEM 1:12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSUR <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) MAY 3 0 1990 W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION V V I I IJ <br /> Ron's Personalized Chevron Service #3 <br /> ADDRESS NELCROSSEET Bmb haCaa PARTNERSHIP ❑ STATEAGUCr O <br /> 139 South Center Street CORPORATION 0 LDGUAGEND ❑ PEDEMLAGENLY <br /> ❑ INDNIDINL ❑ MUIPY.AGENCY <br /> CITY NAME STZIP CODE SITE PHONE#,WITH AREA CODE <br /> Stockton 95202 209-467-1625 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR I ✓Box if INDIAN EPA ID a <br /> © 1 GAS STATION ❑3 FARM ❑ S OTHER RESERTRUSTTVLANDS or ❑ AT THIS SITE <br /> AT THIS TANK'TE 4 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Sanchez, Ronald 209-467-1625 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> Sanchez, Ronald 209-951-7568 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Greyhound Lines Inc, Treasury Dept <br /> MAILING or STREET ADDRESS ✓Boa to,00,cIle ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 4900 Universit CORPORATION ❑ LOCAL-AGENCY 13FEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> West Des Moines IA 50265 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Chevron USA, Inc. <br /> MAILING or STREET ADDRESSyrt✓Boa lo,ndI.M. ❑ PARTNERSHIP ElSTATE-AGENCY <br /> CORPORATEl LOCAL-AGENCY 11 <br /> P.O. Box 5004 NDIVIDUALION 0 COUNTYAG NGV FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a.WITH AREA CODE <br /> San Ramon CA 94583 415-842-9050 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ ill. [93-1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PEN PERJU ,AND E BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> DiAdit) Sa — 30 — 70 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If If of TANKS at SITE <br /> ffm I I I l = <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> �Gy <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE I CENSU�GTNO SUPERVISO DISTRICT CODE BUSINESS P NFIFILED NO ❑ DAM F114�/� <br /> CHECK# PERMIT AMOUNT SURCHARARGE``AMOUNT FEE CODE RECEIPT# BY: <br /> / <br /> THIS FORM MUST BE ACCOWANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3- <br /> 3 j-SS) / <br /> DATA PROCESSING COPY /^//\ <br />