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• '�// • #96465 <br /> TATE OF CALIFORNIA WATER RESOURCE TROL BOARD <br /> FORM 'A': UNDERGROUND STORAGE u <br /> �o <br /> SITE FACILITY/SITE, INFORMATION and/or P6,RtApIT F�$.VCATION <br /> �� �IIf�??JJ 44 <br /> COMPLETE THIS FORM FOR EACH FAC L /SI `'' �'t,voa.��r <br /> MARK ONLY ❑ I NEW PERMIT ® 3 RENEWAL PERMIT 1, GgpP{GF�Q,F1pIFpalpA,y �n Ec 7 PERMANENTLY CLOSED SITE <br /> O <br /> Tt'MLPKAIAVIRIY ISIT/EICCF�SKU lr J <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 E 0 <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Pershing Chevron S �3 <br /> ADDRESS NEAREST CROSS STREET I ✓ftioiNrsk 6 PARTNERSHIP ° STATE-AGENCY <br /> 5608 North Pershing Avenue Robinhood ° WWDUATIGN ° COUNDYGENG+ ° FEDERAL AGENCY <br /> Cl 00RI'DDAi ° LOCAL <br /> LAGENCYY <br /> CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> Stockton CA 95207 209-478-3434 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR V Box If INDIAN RESERVATION or EPA D x If of TANK'S <br /> X❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHEfl TRUST LANDS ❑ AT THIS SITE 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 A WITH AREA CODE <br /> Parks, Brad 209-478-3434 Parks, Bill 209-477-4115 <br /> NIGHTS: NAME(LAST,FIRST) PHONE Al WITH AREA CODE NIGHTS'. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> Parks, Brad 209-952-8616 Parks, Bill 209-478-5447 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> A.G. Spanos <br /> MAILING or STREET ADDRESS I/Box to indicate ° PARTNERSHIP ° STATE-AGENCY <br /> 1341 West Robinhood Drive ° CORPORATION ° LOCAL-AGENCY ° FEDERAL-AGENCY <br /> ® INDIVIDUAL ° COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> Stockton CA 95207 <br /> Ill. 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 5004CORPORATION ° LOCAL-AGENCY ° FEDERAL-AGENCY <br /> ° INDIVIDUAL ° COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEONE N,WITH AREA CODE <br /> PH <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. ❑ 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY D E T OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY P JURISDICTION P AGENCY N FACILITY ID it V of TANKS at SITE <br /> E�l = = I I I � -id <3 <br /> CURRENT LOCAL AGENCY FACILITY IO M APPROVED BY NAME PHONE a WITH AREA CODE <br /> Cl-ae R� <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LCHECK# <br /> N CODE CENSUS TRRAACT M SUPERVVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED q <br /> 1 �✓� 3a1 YES NO � <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTa BY <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 111 OR MORE TANK PERMIT FORM `B`APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) 40 40 <br /> DATA PROCESSING COPY <br />