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#98632 _ 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 ❑ 7 PERMAN EDSITE 7j ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Grantline Chevron ADDRESS NEAREST CROSS STREET ✓Bmlowaaii, N PARRIEIGHP ❑ STATE-AGENCY O 575 West Grantline Road ❑ COIPDRATIM ❑ LOCAL AGENCY o FEDERAU AGM ❑ INEN AL ❑ COUNTY AGENCY CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE Tracy CA 95376 209-836-1233 TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑4 PROCESSOR I I/Emir INDIAN EPA ID N © 1 GAS STATION [—]3 FARM ❑ 5 OTHER TRUST LANDS ur ❑ N of HIS SITE AT THIS STE Q EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE 1 Meservy, Jim 209-836-1233 Cecchini, Leo 209-836-1233 NIGHTS. NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS. NAME(LAST.FIRST( T Mesery , Jim 209-835-9405 II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) JUN ? 7 1990 NAME CAPE OF ADDRESS INFORMATION Oma Rickman ENVIRONMENTAL HEALTH MAILING or STREET ADDRESS ✓Box to indicate PARTNERSHIP PERM17ASM ES P.O. Box 244 E3CORPORATION Ll LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATEZIP CODE PHONE N,WITH AREA CODE Tracy CA 95376 111. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Chevron USA, Inc. MAILING or STREET ADDRESS ✓Boz to indicate ❑ PARTNERSHIP ❑ STATE AGENCY XI Cl LOCAL AGENCY P.O. Box 5004 ❑ NDIIVIDUALION ❑ COUNTY—AGENCY ❑ FEDERAL-AGENCY CITY NAME STATE ZIP COOE PHONE a.WITH AREA CODE San Ramon CA 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. ❑ R. ❑ III. X❑ THIS FORM HAS BEEN COMPLETED UNDER PEN PERJ RY, ND 7 BE OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE � vII� G_ SON1Jsonl 6- t 5 - `(o LOCAL AGENCY USE ONLY COUNTY N JURISDICTION N AGENCY11 aaaaa� ACILITY ID N K of TANKS at SITE [R L,—H / I V 16) 1 ?1 1 1 1 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE ✓,e PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 3-214YES ❑ NO le�110_ L0 CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN BY: „ A F� si THIS FORM MUST BE ACCOMPANIED BY AT LEAST(11 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLERC THIS IS A CHANGE OF SITE INFORMATION ONLY.Q FORMA(3-2-88) b "'Iss"Ma" DATA PROCESSING COPY