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STATE OFCALIFORNIA c <br /> w I T`y '� ,dp STATE WATER RESOURCES CONTROL BOARD o <br /> I. A UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> APR 9 19 31 <br /> ,, COMPLETE THIS FORM FOR EAC ACILrry/SRE #764 <br /> f <br /> 'EREaLgEW PERMIT ® 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> rL r11 LJ 2 INTERIM PERMIT Q 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE (y <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> APSI Chevron U.S.A. Inc. <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTXINgy <br /> 4747 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95210 209-956-2520 <br /> I/ Box <br /> TO INDICATE (XI CORPORATION Q INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY O COUNTY-AGENCY ED STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ® 1 GAS STATION Q 2 DISTRIBUTOR ✓RESERVATION <br /> IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(wfi-W) <br /> Q 3 FARM O 4 PROCESSOR Q 6 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Arnold Laurie 209-956-2520 Gomez Amanda 209-956-2520 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Same 209-521 -7220 Same 209-478-9552 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Chevron U.S.A. Inc. <br /> 7 MAILING OR STREET ADDRESS ✓ box b Indic aN Q INDIVIDUAL O LOCAL-AGENCY I= STATE-AGENCY <br /> P.O.BOX 5004 �1L]CORPORATION O PARTNERSHIP =COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE WITH AREA CODE <br /> San Ramon CA 94583 415-842-9050 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Chevron U.S.A. Inc <br /> MAILING OR STREET ADDRESS ✓ box bindkaN 0 INDIVIDUAL = LOCAL-AGENCY El STATE-AGENCY <br /> P.O.BOX 5004 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> San Ramon CA 94583 415-842-9050 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)739-2582 if questions arise. <br /> TY(TK) HQ 14F4]-�� <br /> V. 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 SHOULFOR LEGAL NOTIFICATIONS AND BILLING: I.0 II.O <br /> THIS FORM HAS BE COM UN R*ALTY191 E URY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTWDAYNEAR <br /> V -. 5aa�fs <br /> ul A s� - / 9/ <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# 'JURISDICTION# FACILITY# /� " <br /> E=_1 �il' V r 17 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> O x <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B, UNLESS THIS IS A CHANGE OF strE INFORMATION ONLY. <br /> �FQRM A(9-90) FOfl0039q fl2 <br /> i�0 'C� <br />