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a � <br /> !�' vuaesa <br /> STATE OF CAUFORNIA h&r <br /> 5 8# STATE WATER RESOURCES CONTROL2 CONTROLD 4Q <br /> -U E TGE TANK PERMIT APPLICATION-FORM A ° <br /> I` 3 I~w COMPLETE THE FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1--1 OIT 2: 3 RENEWAL PERMIT fX-1 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERW N 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ADDRESS NEAREST CROS§STREET PARCEL#(OPTIONAL) <br /> CITY NAME STATE SITE PHONE#WITH AREA CODE <br /> I/ BOX <br /> TO INDICATE CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY• Q STATE-AGENCY' Q FEDERAL-AGENCY <br /> DISTRICTS, <br /> If owner of UST is a public agency,complete the following:nam of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS ' GAS STATION Q 2 DISTRIBUTOR ® RESERVATIONINDIAN if OF TANKS AT SITE E.P.A. I.D.#(aptiona!) <br /> 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY).optional <br /> DAYS: NAME(LAST FIRST) PHONE#WITH AREA CODE DAYS:NAME(LAST,FIRST) PHONE#WIT AREA CODE <br /> `3 2 31 ( Q-C 3 <br /> NIGHTS: NAME(LAST,FIRST) PHONE f WITH AREA CODE NIGHTS: N E(LAST.FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> CHEVRON USA PRODUCTS CO. <br /> MAILING OR STREET ADDRESS ✓ box b Indkate Q 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 PHONE#WITH AREA CODE <br /> SAN RAMON, CA 94583 (510) 842-9500 <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> CHEVRON USA TS CO. f <br /> MAILING OR STREET ADDRESS ✓ b0XIDkdc0 IQ 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 PHONE#WITH AREA CODE <br /> SAN RAMON, CA 94583 ��l(510) 842-9500 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ 4 4- -10 13 1 1 9 1� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THEM OD(S) USED <br /> ✓bDxtoindkate ® 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETV�ND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.= 11.= 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 MONTHIDAYIYEAR <br /> KATHY NORRIS ,-- MKTG ASST j- <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# n <br /> LOCATION CODE -OPTIONAL CENSUS TRACT#-OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> S FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PER LK;A • FORM B,UNLESS THIS LR A CHANGE OF srrE IwoRmAm ONLY. <br /> FORM A ) OWNER MUST FILE THE FORM WITH THE LOCAL AGENCY IMPLEMENTINGTHE UNDERGROU&STORAGE TANK REG 3"7 <br />