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• • U6OU^ ^ <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s ` <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FO <br /> COMPLETE THIS FORM FOR EACH FACIUfYISITE <br /> MARK ONLY F-1 f NEW PERMITI�I� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION �I/7 PERMANENTLY CLOSED SITE <br /> ONE ITEM O2 INTERIM PERMIT u d AMENDED PERMIT O S TEMPORARY SITE CLOSURE MAY `j <br /> I. FACILITYISITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) 4-40101 <br /> DBAOR FACILITY NAME ' t,. ,µ, NAME OF OPERATOR �UNPER WNTq(NE <br /> �Rj� ISS ao0 MIT <br /> ADDflES3 , /� �— NEARESTCROSS STREET- PARCEL#( <br /> CITY NAME S STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> oG(C !'v ca S 0 c;20 - <br /> ✓ Box LOCAL-AGENCY <br /> TOINDICATE CORPORATION INDIVIWAL O PARTNERSHIP DISTRICTS' 0 COUNTY-AGENCY' O STATE AGENCY' FEDERAL-AGENCY' <br /> Owner of UST Is a public agency,complete the following:name of Supervi,or of division,section,or oNlcs which operates the UST <br /> TYPE OF BUSINESS t GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(aprlmelY <br /> 0 o Q RESERVATION CAL 000/v76S <br /> 3 FARM 0 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DSYS: NAME(LAST,FIRST) E# TH AREA CODE D S: NAME(LAST,F R PHONE#WITH A EA CODE <br /> L/J s o n! LUAA _ L- �N nl " �E 8017-f� 3S� <br /> NIGHTS: NAME(LAST,F9ST1, il <br /> ONE ITH AREA CODE �� IGHTS: NAME(�.FIR Sn PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> 'MEVRON U.S.A. PRODUCTS CAfiE0E.A ff%C "A4TION <br /> MAILING OR STREET ADDRESS ✓ bUtolndIcals O INDIVIDUAL O LOCAL-AGENCY O STATE-AGENCY <br /> P.O. BOX 5004 CORPORATION O PARTNERSHIP = COUNFY-AGENCY = FEDERAL AGENCY <br /> CITY NAME STATEZIP CODE PHONE#WITH AREA CODE <br /> SAN RAMON CA 94583 510-842-9002 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> CHEVRON U.S.A. PRODUCTS KATHY NORRIS <br /> MAILING OR STREET ADDRESS ✓ Em NirEmala [:1 INDIVIDUAL E3 LOCAL-AGENCY O STATEAGENCY <br /> P.O. BOX 5004 ®CORPORATION ID PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> CA 94583 <br /> 51 <br /> SAN RAMON (,A —842-9002 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HO 4 4- - Q 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bm bind"16 t SELF INSURED =2 GUARANTEE I� 3 INSURANCE 0 A SURETY BOND <br /> O 6 LETTER OF CREDIT =6 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ It.[—] III. <br /> T141S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OFMY KNOWLEDGE,IS TRUE AND CORRECT <br /> O NER'S NAME(PRINTED SIGNED) OW R'S TITLE DATE MCNTHVDAYIYEAR <br /> Z4-71 L. �T6. s i S <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> EN 2 324 2 <br /> LOCATION CODE -OPTIONAL CENSUSTRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTVA14L <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGR*STORAGE TANK REGULATIONS <br /> FORMA(393) Fgie033AA7 <br />