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#99840 <br /> 9 0[FA ThF, <br /> STATE O F- CALI FO R N I WATER RESOURCES CONTROL BOARD <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PRO <br /> SITE F CILITY/SITE, INFORMATION and/or PERMIT <br /> COMPLETE THIS FORM FOR EAC ACILITY/SIT ""Fo"N4" <br /> All MA <br /> MARK ONLY ❑ 1 NEW PERMIT a 3 RENEWAL PERMIT 36 5 CHANGE OF INFORMATION P ENTLY CLOSED SITE A'y <br /> �g1L p� �/1 <br /> •Q <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT El TEMPORARY SITEN&bRON M ENTAL H EAL I H <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) FEHMIT/SERVICES W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Andy's Chevron <br /> ADDRESS NEAREST CROSS STREET ✓Boz to indicate N PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 4400 Waterloo Road ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE it,WITH AREA CODE <br /> Stockton CA 95205 209-931-2186 <br /> TYPE OF BUSINESS: ❑p DISTRIBUTOR ❑4 PROCESSOR ✓Box i1 INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> ® 1 GAS STATION 0 3 FARM ❑5 OTHER TRUST LANDS ❑ AT THIS SITE 4 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br />' Dahlenburg,Gary 209-948-1661 Huntsman, Darrell 209-466-8651 <br /> /NIGHTS: NAME(LAST,FIRST) PHONE At WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Dahlenbur ,Gary 209-887-3105 Huntsman,Darrell 209-478-0930 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> AME CARE OF ADDRESS INFORMATION <br /> Frank&Antoinette Busiselich <br /> AILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 11 LOCAL-AGENCY <br /> 4514 Waterloo Road 1:1 NDIVIDUALION ❑ COUNTY-AGENCY ❑ FEDERAL-AGENCY <br /> L-rTY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> Stockton CA 1 95201 <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> ,NAME CARE OF ADDRESS INFORMATION <br /> Chevron USA, Inc. <br /> AILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ly P.Q. BOX 5004 CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> INDIVIDUAL ❑ COUNTY-AGENCY <br /> C NAME STATE ZIP CODE PHONE Al,WITH AREA CODE <br /> San Ramon CA 94583 415-842-90.50 <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. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AN THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> 'DAVID & J,_6409-4 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> CURRENT L AL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> Oh yr <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCA ODE CENSUS TRA # SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE/FILE <br /> �3 l CJ�� YES ❑ NO ❑ to & �CJ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST R MORE TANK PERMIT FORM 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> �CJ <br /> FORM A(372-88) <br /> 4 DATA PROCESSING COPY <br />