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850URCeS <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD P <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a�� 2D <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F7, t NEW PERMIT 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION F-] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM D 2 INTERIM PERMIT 4 AMENDED PERMIT F-1 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITYISITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERp�OR <br /> C�jyW y� 1-fUmod Tre►IPLn <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CIN NAME STACE4 Z �pE�I SITE PHONE PITH QR�C{) <br /> TOINDIC TE O CORPORATION F-1 INDIVIDUAL [:1 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 0 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION /l. <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: _NAME(L�TS�T) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) o <br /> NIGHTS: NAME(LAST,F T) PHONE`#�Tjt jQj y NIGHTS: NAME(LAST,F RST) <br /> `J <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAM .rCARE OF ADDRESS INFORMATION <br /> K -! An}otneHe �3udlsel�sh <br /> MAILING OR STREU ADDRESS rte,` �j ✓ box bindicate INDIVIDUAL = LOCAL-AGENCY STATE-AGENCY <br /> 4 S I Lo ke io,, jzA 0 CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAI 1 O n STATE ZIP�O��� I PHONE#WITH AREA CODE <br /> T <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE qFNADDRESS INFORM ION <br /> CHEVRON USA INC. vecP-\—k <br /> MAILING OR STREET ADDRESS• ✓ box b indicate = INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 500 CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SAN RAMON CA 94583 � (510) 842-9002 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ �4 4�-l u l3 I I Iq 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate V t SELF-INSURED E:1 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT E�]6 EXEMPTION F1 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.El II.El I <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED 8 SIGNA U E) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> KATHY L. NORRI S UAWMKTG. AST. <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE OPTIONAL CENSUS TRACT# -OPTIONAL 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 /> FORM A(1z-91) FILE THIS FORM WITH TH LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A-R6 <br />