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• • .W^ f <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A =. <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE `'�•"^"'• <br /> MARK ONLY 1 NEW PERMIT Q 3 RENEWAL PERMIT J�S CHANGE OF INFORMATION O T PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT 4 AMENDED PERMIT Q e TEMPORARY SITE CLOSURE <br /> I. FACILrrYISITE INFORMATION 8 ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME 14 <br /> C ( (� O NAMEOFOPERATOR <br /> ADDRESS ,/'J (�,� NEAREST CROSS STREET PARCEL#(OPfgNAW <br /> CITY NAME STATE ZIP CODE,,,, O SITE PHONE#WITH AREA CADS- <br /> �J TpG(C !vOpo 1^ <br /> ✓ <br /> BOX CORPORATION D CCORPORATIONl�INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY O DISTRICTS' COUNTY-AGENCY' DSTATE-AGENCY, O FEDEML-AGENCY?' <br /> •ff owner d UST le a public agency,complete the following:name d Supervisor d c Nislon.section,or office which operates the UST <br /> TYPE OF BUSINESS t GAS STATION Q 2 DISTRIBUTOR Q R TIFF INDIA #OF TANKS AT SITE E.P�P.eeA. I.DD..#(op#mW) / <br /> 3 FARM Q 4 PROCESSOR Q 5OTHER OR TRUST LANDS A.�l1•, s/Q0/U 7(�� <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS NS(LAST.FIRST) r��1�� E# TH AREA CODE D S: E(LAST,F R PHONE i WI-H AREA <br /> NIGHTS: NAME(LAST,F�ST)m 'f C, P^HHONE# THAREACODE �� IGHTS: NAME(LAST•FIR Sn - Ln!//PHONE C#MNWITH/TAREA CODE <br /> Q G77 !LT{LAn <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME :Z U.S.A. t'1dUiJl.iC;'. CAR60F.ADOR6S9JN MATION <br /> 1'7 <br /> MAILING OR STREET-ADDRESS ✓box bidkat# l� INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 50004 CORPORATION Q PARTNERSHIP O COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> A SAN RAMC- CA 94583 510-842-9002 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> CHEVRON U.S.A. KATHY NORRIS <br /> MAILING OR STREET ADDRESS ✓ box 13 Wicate 0 INDIVIDUAL E3 LOCAL-AGENCY 0 STATE-AGENCY <br /> P.O. BOX 5004 (X CORPORATION [:::) PARTNERSHIP 0 COUNTY-AGENCY ED FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SAN RAMON CA 583 510-842— 2 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322.9669 if questions arise. <br /> TY(TK) HQ 4 F4-]- <br /> V. <br /> - -V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ bor 0indicate 1 SELF-INSURED 712 GUARANTEE [:] 3 INSURANCE O 4 SURETY BOND <br /> �5 LETTER OF CREDIT ED S EXEMPTION L-1 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. II. III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OPYERS NAME(PINTED SIGNED) ' 4/f OWN R'STTLE DATE MONTWDAYIYEAR <br /> LOCAL XGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -GPTIONAL CENSUS TRACT# -OPTIONAL BUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SrrE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGR IQ�"'�STORAGE TANK REGULATIONS <br /> FORMA(3M) OWNER <br />