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zEp^OfI,M <br /> • SPATE OF CALIFORNIP WATER RESOURCES CONTROL BOARD l.'�. <br /> FORM `A': m <br /> UNDERGROUND STORAGE TANK PROGRAM �a <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT ❑ 3 RENEWAL PERMITi. 5 CHANGE OF INFORMATION ❑ 7 PERMANENT SED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE ' <br /> 10 <br /> 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> CHEVRON USA. INC. <br /> ADDRESS NEAREST CROSS STREET ✓Box w,dote ❑ PAWNERSHIP ❑ STATE AGENCY <br /> 4747 WEST LANE BIANCI CORPORATION ❑ LOCAL AGENCY ❑ FEDERAL AGENCY <br /> El ITE <br /> 1:1COUNTYAGENCY <br /> CIT'NAME STATE ZIP CODE SITE PHONE 4,WITH AREA CODE 'A <br /> T CA 95202 NONE <br /> TYPE OF BUSINESS ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID it <br /> RESERVATION Or R of HIS SI <br /> © I GAS STATION [:] 3 FARM S OTHER TRUST LANDS ❑ AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(I-AST,FIRST) PHONE k WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> CHEVRON (DISPATCH)(800)423-3520 CHEVRON (DISPATCH)(800)473-3520 <br /> NIGHTS: NAME(LAST,FIRST) PHONE 4 WITH AREA CODE NIGHTS'. NAME(LAST.FIRST) PHONE It WITH AREA CODE <br /> CHEVRON (EMERGENCY)(415)897-0244 CHEVRON (EMERGENCY)(415)877-0244 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> CHEVRON USA INC. <br /> MAILING or STREET ADDRESSar!Box to indicate 11 PARTNERSHIP ❑ STATE-AGENCY <br /> e CORPORATION ❑ LOCAL-AGENCY ❑ FEDERALAGENCY2410 CAMINO RAMON ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE b,WITH AREA CODE <br /> SAN RAMON CA 94583 (415)842-9500 <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION . <br /> rHF.VRON USA, INC. MAI Vt "Lill- <br /> MAILING <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 7Q STIE-��1' <br /> ❑ CORPORATION ❑ LOCAL-AGENCY OC IC FEL14RA(�AGACY <br /> ❑ INDIVIDUAL ❑ COUNTY-A EN Y <br /> CITY NAME STATE ZIP CODE t INV IIIC <br /> ERM ILEE I <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. ❑ if. ❑ III. ❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME PRINTED&SIGNATURE) / DATE <br /> HELEN LOR TOROBERT H. LEE & A SOC. 10-05-90 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY M JURISDICTION It AGENCY k FACILITY ID R R of TANKS at SITE <br /> F3-T-,Fl = = 16161AFa EolOI0131 <br /> CURRENT LOCALAGENCY FACILITY ID It APPROVED BV NAME PHONE N WITH AREA CODE <br /> CACIP-lz� 4-1 7 <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRA CS kSUPERVISOR-DISTRICT CODE BUSINESS PUN FILED DATE FILED <br /> YES NO la <br /> CHECK% PERM AM UNT✓ SURCHARGE AMOUNT FEE CODE RECEIPT X BY: C v <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 /> `1 FORM A(3-2-BS) <br /> DATA PROCESSING COPY v <br /> VVJJ O Q <br />