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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD ~ <br /> .i <br /> ti <br /> FORM 'A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY © 1 NEW PERMIT ❑ 3 RENEWALPERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMA LY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑ 4 AMENDEDPERMIT ❑S TEMPORARY SITE CLOSURE I •� <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> CHEVRON U.S.A. , INC. ,Ay�P•5 <br /> ADDRESS NEAREST CROSS STREET ✓AmlondiCak 0 PAATNERSMP 0 STATE-AGENCf !�• <br /> CAIVOPATIOI 0 LOCAL-AGENC/ 0 FEDOW.-AGRO <br /> 4747 WEST LANE BIANCI INDMGGAL ❑ oomy-AGENIX <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> STOCKTON CA 9520 NONE <br /> TYPE OF BUSINESS: F--12 DISTRIBUTOR ❑4 PROCESSOR */Box it INDIAN EPA ID N <br /> RESERVATION or #of TANK'a <br /> © 1 GAS STATION ❑3 FARM ❑S OTHER TRUST LANDS I AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE p WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE p WITH AREACODE ' <br /> 23-3528 CHEVRON DISPATCH 800 423-3528 <br /> NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE p WITH AREA CODE <br /> CHEVRON (EMERGENCY) (415) 877-0244 CHEVRON (EMERGENCY) (415) 877-0244 <br /> IL PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME .CARE OF ADDRESS INFORMATION <br /> CHEVRON U.SA. , INC. <br /> MAILING or STREET ADDRESS ✓8ox to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> <CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 2410 SI INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE If,WITH AREA CODE <br /> SAN RAMON CA 94583 (415) 842-9500 <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> CHEVRON U.S.A. , INC. <br /> MAILING or STREET ADDRESS ✓Box to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> [M Cl LOCAL-AGENGY <br /> 2410 CAMINO RAMON 0 I DIIVIDUALION 0 COUNTY AGENCY OFEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> SAN RAMON CA 94583 (415) 842-9500 <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. ❑X 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NAME(PRINTED&SIGNATURE) R� T H. LE OCIATES DATE <br /> RANDALL BRAKE 06/ 15/90 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY k JURISDICTION# AGENCYIN FACILITY M of TANKS at SITE <br /> -,)-I 10Q03 <br /> CURRENT LOCAL C LITY ID# APPROVED BY NAME PHONE If WITH AREA CODE <br /> PERMIT N AL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT If SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> O / O<- 3 ' / D � RI�-- YES ❑ NO E] <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY ATL ST(1)OR MORE TANK PERMIT FORM 'B' APPLICATION(S),.UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. . <br /> FORMA(3-2-88 <br /> �S(1 DATA PROCESSING COPY <br />