Laserfiche WebLink
#94183 _ <br /> STATE OF CALIFORO WATER RESOURCES CONTR BOARD yEPr. "'"' <br /> mP.. .•aA <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM =� T <br /> �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE "L FOR"`° <br /> MARK ONLY ❑ 1 NEW PERMIT ® 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION 7 P tj <br /> ITE Q <br /> ONE ITEM ❑ 2 INTERIM PERMIT El AMENDED PERMIT ❑6 TEMPORARY SITE CLOSUREhNONE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ENVRONMENTAt W <br /> Lakewood Chevron PERMIT/SERVICES W <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate n PARTNERSHIP Cl STATE-AGENCY <br /> 236 North Ham Lane Lockeford Lane ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Lodi CA 95240 209-334-2241 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR7B0. DIAN EPA ID #© 1 GAS STATION ❑ 3 FARM ❑5 OTHER RESETI <br /> RESEDS ATION�r ❑ AT THIS SITE 4 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Priest, Jack 209-334-2241 Chevron Maint. Dept. 800-772-3301 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Priest, Jack 209-473-3641 Chevron Maint.Dept. 415-877-0244(24hr) <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Wells Fargo Bank <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> P.O BOX 63700 ® CORPORATION 1-1LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> San Francisco CA 1 94163 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Chevron USA, Inc. <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> P.O. Bax 5004 CORPORATION ElLOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> San Ramon CA 94583 415-842-9050 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ III.Q <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL PERJURY, TO E F MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID#' #of TANKS at SITE <br /> m <br /> CURRENT LOCAL AGENCY IFACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST OR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY 0 <br />