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STATE OF CALIFORMA ,[ ''� <br /> STATE WATER RESOURCES CONTROL BOARD W„ -:a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :- <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `-��ra-+�' <br /> MARK ONLY ❑ I NEW PERMITI`I❑� 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION [_-] 7 PERMANENTLY CLOSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT u 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION 3 ADDRESS-(MUST BE COMPLETED) <br /> OBAOR FACILITY NAME NA EOFOPERATOR <br /> Chevron Station #2ooZ (oy 4pS 1 5 , ��h ►�� a �, c,g p� <br /> Ch,. R00 The Chevron Comp, .IeS CHECK DATE 02/01/96 <br /> y 0061 <br /> CHEVRON U.S.A. INC. PAGE 01 OF 01 <br /> P.O. Box S, Concord, CA 94524 <br /> INV DATE INVOICE NO. ORDER IDENTIFICATION REF. NO. GROSS AMOUNT DEDUCTIONS NET AMOUNT <br /> 01/22/96 025661 01A6JQ015NW 510.00 510.00 <br /> 4747 WEST LN STOCKTON <br /> INQUIRE - PO BOX W, SECT 454, CONCORD, CA 94524 TOTAL 510.00 <br /> DIRECT QUESTIONS TO: (510) 842-9576 NW <br /> PAYEE 000275344 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL BANK NWR 00147 <br /> 001 <br /> Check No. 100 49904 07 <br /> X-UCA091 (08-90) <br /> LwAitirvwut -UPINNAL ICtNSUS IRACTIT -OPTIONAL ISUPVISOR-DISTRICT CODE -OP77OW 3(3I! I <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INJORIMAT16N-ONLY. <br /> FORMA(393) <br /> OWNER MUST FILE THIS FOPW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO STORAGE TANK REGULATIONS <br /> Fpgy36Ri <br />