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t� e <br /> STATE OF <br /> STATE WATER RESOURCES CONTROL D W` <br /> s STORAGETANK PERMIT Ll I �P <br /> f 2 ) <br /> COMPLETE THIS FORM FOR EACH FACILITY/S <br /> 10 <br /> ARK ONLY 0 1 NEW PERMIT E:j 3 RENEWAL PERMIT 'Z'6 CHANGE OF INFORMATION E:] 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 02 INTERIM PERMIT a 4 AMENDED PERMIT Ll 6 TEMPORARY SITE CLOSURE <br /> 1. CIL /SITE INFORMATION ADDRESS-(MUST BE COMPLETED) <br /> DBA OR F I ITY NAME ` NAME OF OPERATOR <br /> ADDRESS ® NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> CITY NAME STACA SITE PHONE#WITH AREA ick CODE <br /> ✓ �X R RATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL•AGENGY Q COUNTY-AGENCY° Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> R 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—y, GAS STATION 02 DISTRIBUTOR ® REV IF SERVA®IIANON #OFTANKS AT SITE E.P.A. I.D.is(optional/ <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER ORTRUSTLANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> D YS:NAME(LAST,FIRST) ., PHONE# ITH AREA CODE DAY E(LAST,FIRS PHONE#WITH ARE CODE _ <br /> ne - t 0J t Cn Ce <br /> NIG : NAME(LAST,FIRST) PHONE#W TH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> CHEVRON USA PRODUCTS CO. <br /> MAILING OR STREET ADDRESS ✓box I)indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> P.O. BOX 5004 E:N CORPORATION ® PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONN vvyyliiH CO <br /> SAN RAMON, CA 94583 lUl �+�L-4500 <br /> III. TANKgWNE INFORMATION-(MUST BE COMPLETED) <br /> NAME O C WON USA PRODUCTS CARE OF ADDRESS INFORMATION <br /> KATHY NORRIS <br /> MAILING OR STREET ADDRESS ✓box w IndicateQ INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> P.O. BOX 5004 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE C <br /> SAN RAMON, CA 9458��F`Hlegj�l�l`94 09902 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBS -Call(916)322-9669 if questions arise. <br /> T (T ) H - -1 013 1 119 1 113 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to Indicate 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 19 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. it. 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 MONTHlDAYtNEAR <br /> KATHY NORRIS MKTG. ASST. <br /> L AL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 3UPVISOR-DISTRICT CODE -OPnONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT AUCAT - FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA ) OWN UST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING T UNDERGROUND AGE T REGULATIONS <br />