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L G #95490 _ <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD '" ' <br /> FORM IA': <br /> UNDERGROUND STORAGE TANK PROGR � <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT AP� a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT ® 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION 7 PERMANENT 0 <br /> ONE ITEM E] 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITECLOFUNVIRO ENTAL F� <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> tit jjI/0F_T%YIVw� <br /> W <br /> ��A <br /> f <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION `y <br /> Bob and Vans Chevron IA <br /> ADDRESS NEAREST CROSS STREET ✓SmbNok PARTNDt91IP Cl STATE AGENCY 1✓ <br /> 1246 E. Harding Way ❑ CORPORUIGN ❑ LOCAAGDO ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ CUUNTYAGENCY <br /> CITY NAME STATE ZIP CO E SITE PHON #WITH AREA ODE <br /> Stockton CA §5205 209-463-53 7 <br /> TYPE OF BUSINESS'. ❑ 2DISTRIBUTOR ❑ 4PROCESSOR ✓Box if INDIAN EPA ID # #of TANKI <br /> ® 1 GASSTAT10N ❑ 3 FARM ❑5 OTHER TRUSESETVATION LANDS dr ❑ AT THIS SITE 4 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE It WITH AREA CODE <br /> Jones, Bob 209-463-5337 Maintenance Dispatch 800-772-2415 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) PHONE Al WITH AREA CODE <br /> Jones, Bob 209-951-0696 800-772-3301 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Chevron USA Inc. <br /> MAILING or STREET ADDRESS ✓Box to indicate 11PARTNERSHIP 11STATE-AGENCY <br /> P.O. BOX 5004 ® CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONEPWITH AREA CODE <br /> San Ramon CA 94583-0804 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Chevron USA, Inc. <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> P.O. Box 5004 ffi CORPORATION ❑ LOCALAGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> San Ramon CA 94583 415-842-9050 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDERPE JURY, ND TO(HE TO MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> vl DH►x,II3 - a - ,a <br /> LOCAL AGENCY USE ONLY <br /> COUNTYA, JURISDICTION IF AGENCY# CILITY ID# #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT X 2SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FIfFO <br /> 01 237. g'� /Z�j YES NO ❑ Z ZS q/ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:,f� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST/1)OR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) r, <br /> DATA PROCESSING COPY <br />