BILLING_PRE 2019 - Laserfiche WebLink

Home Browse Search

STATEOFCALIFORNA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACHFACILRY/SITE MARK ONLY D I NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SITE ONE REM 0 2 INTERIM PERMIT 0 4 AMENDED PER a TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FAe-4�CILITY NAME NAME OF OPERATOR e.1 c n ADDRESSNEAREST CROSS STREET PARCEL#(OMONAL) 'est LCLL'`-� R k a r\c k, CITY NAM STATE ZIP CODE SITE PHONE#WITH AREA CODE I/ BOX 1o�ki-Gn Ca I q 5a0-) 2D Q- q 5-�. zsa TOINgCATE CORPORATION O INDIVIDUAL 0 PARTNERSHIP O LOCAL-AGENCY O COUNTY AGENCY' O STATE AGENCY' O FEDERAL-AGENCY" DISTRICTS' If owner of UST Is a public agency,mnplale the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOfl O */ IF INDIAN A OF TANKS AT SITE E.P.A. I.D.#(cpnow/) RESERVATION 3 FARM O 4 PROCESSOR E 5 OTHER OR TRUST LANDS 3 CfiLo O EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE R L Z - q - _zs ap ; NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION CHEVRON USA PRODUCTS CO. MAILING OR STREET ADDRESS ✓ box biMkale 0 INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY P.O. BOX 5004 hI1]CORPORATION = PARTNERSHIP O COUNTY-AGENCY [_1 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PH # TH C SAN RAMON, CA 94583 � 1 ��+�2-� 00 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOF OWN R CARE OF ADDRESS INFORMATION CHENON USA PRODUCTS KATHY NORRIS MAILING OR STREET ADDRESSy�✓,boa b indloale [__j INDIVIDUAL LOCAL Q STATE-AGENCY P.O. BOR 5004 'T._I CORPORATION = PARTNERSHIP COUNTY AGENCY FEDEMLAGENCY CITY NAME ST`AATE 21P CODE 94583 PHONE#WITH AREA CODE SAN RAMON, (510) 842-9002 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- 0 3 1 9 1 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USED ✓ boa to MEate I SELF INSURED (]2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND 5 LETIEROFCRELYT O 6 EXEMPTION Q 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE ONTW AYNEAR KATHY NORRIS MKTG. ASST. LOCAL AGENCY USE ONLY COUNTY If JURISDICTION# FACILITY# 3q 2y82 LOCATION CODE -OPTIONAL CENSUS TRACT i -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKMiB FORM q(393) //�7-(/,T//�/ �'(/ / FOR/ON3gli7 • • � Il.l'/// f I \,I I I ACl /()L 1.