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STATE OF CALIFORNIA <br /> .. 1 gg II STATE WATER RESOURCES CONTROL BOARD <br /> IICbi6mom/ ya° <br /> -4J OUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> L, � COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY r 1 rN •RVP F73 RENEWAL PERMIT 0 6 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED SITE <br /> ONE REM Q 2 INTERIM PERMIT 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> e�7ro 200 t <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPfIONAU <br /> Ll-74 A. l <br /> CITY NAME - STATE LP CODE SITE PHONE a W ITH AREA CODE <br /> sk C CA d - Slo -2-0 <br /> T INDICATE0 4'CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' O STATE-AGENCY' O FEDERAL-AGENCY' <br /> DISTRICTS' <br /> N owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS r��i GAS STATION 2 DISTRIBUTOR ✓ IF IND IAN Is OF TANKS AT SITE I E.P.A. I.D.a toplMnal) <br /> RESER <br /> 0 3 FARM 4 PROCESSOR 0 6 OTHER OR TRUSTV <br /> ATION <br /> QLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIfjST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> w�11 209-956-'-,� yvru S O 4b3- 4a373 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NA (LAST.FIRST) PHONE a WITH AREA CODE <br /> S 20 -O ry 2.f 510 6-029, <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> CHEVRON USA PRODUCTS CO. <br /> MAILING OR STREET ADDRESS ✓boa blnskaN O INDIVIDUAL D LOCAL-AGENCY STATE AGENCY <br /> P.O. BOX 5004 )(]CORPORATION 0 PARTNERSHIP CWNrYAGENCY 0 FEDERAL AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> SAN RAMON, CA 94583 (510) 842-9500 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> CHEVRON USA PRODUCTS CO. <br /> MAILING OR STREET ADDRESS ✓bozb Wkap INDIVU)VAL LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 5004 );]CORPORATION 0 PARTNERSHIP COUNrYAGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE—#WITH AREA CODE <br /> SAN RAMON, CA 94583 (510) 842-9500 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER•Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- 0 3 1 9 1 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ boabindkah, )d 1 SELF-INSURED I__1 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 gg 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.D II.0 III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE MONTH/DAY/YEA <br /> KATHY NORRIS MKTG ASST <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY f <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACTS -OPTIO SUPVISOR-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 SITE INFORMATION ONLY. <br /> FORMA(393) • <br /> OWNER MUST FILE THIS FORM jjTHE LOCAL AGENCY IMPLEMENTING THE UNOERGROUNQ,�STORAGE TANK REGULATIONS <br /> FOR0033AA7 <br />