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6 t <br /> STATE OFCAUFOFNA fe t'o <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE `'�•o��'' <br /> MARK ONLY O 1 NEW PERMIT 3 RENEWAL PERMIT S CHANGE OF INFORMATION 0 7 PER N L D SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Chevron Station # • 7-0 k-1 l,.\ 'APS1 s <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAM <br /> M k trs 4S. VA c-.kv1 S M,t 5 t <br /> CITY NAME A STATE ZIP CODE� SITE PHONEi ITH AREA CODE <br /> IS <br /> CA <br /> ✓ BOX X1. <br /> LOCAL <br /> TO INDICATE ORPORATION INDIVIDUAL PARTNERSHIP DISTRICTS' <br /> 0 COUNTY-AGENCYSTATE-AGENCY' 0 FEDERAL-AGENCY' <br /> 'IfownerdUSTisapency, <br /> complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESS 141 1 GAS STATION Q 2 DISTRIBUTOR = RESERVATIONINDIAN <br /> x OF TANKS AT SITE E.P.A. 1.D.X(optional) <br /> l� 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS (� V ` —t <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> AYS: NAME(LAST,FIRST) COD DAYS: NAME(LAST,FIRST) PHONE.WITH AREA CODE <br /> 0c�a�1 <br /> H S NAME(LAST FIRS PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �v� � s1 22 : -I -I - <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMc CARE OF ADDRESS INFORMATION <br /> x y� <br /> MAIPOR STREET ESS ✓box b indicate =INDIVIDUAL = LOCAL-AGENCY =STATE-AGENCY <br /> , 0 . �O CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY =FEDERAL-AGENCY <br /> CITY t�ME "'� � TAZE� ZIP CODE PHONE>f WITH AREA CODE <br /> mIII. TANK OWNER 1 INFORMATION-(MUST BE COMPLETED) `J G4 <br /> NAME OF OWNER CARE F DDR S INFORMA 10 <br /> Chevron U.S.A. Products Company 151-r <br /> r 13 <br /> MAILING OR STREET ADDRESS P.O. BOX 5004 ✓ box b indicate INDIVIDUAL a LOCAL-AGENCY =STATE-AGENCY <br /> .CORPORATION O PARTNERSHIP =COUNTY-AGENCY = FEDERAL-AGENCY <br /> CITY NAME San Ramon STATE I ZIP CODE 94583 PHONE N WITH A,RE1^A�CODEE, <br /> 51 "1 /��`'� <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - 0 131119 1 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box to indicate 541 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> = 5 LETTER OF CREDIT 6 EXEMPTION (]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.❑ II.[�] 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 DATEZTH/D NEAR•r � � S+ z <br /> LOCAL WGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> ® 12-1312 S <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT COD -OPTIONAL �jl <br /> 3LIy <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE I uAlnok ONLY. <br /> FORMA(3193) <br /> OWNER MUST FILE THIS FORIAG THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO ORAGE TANK REGULATIONS <br /> RMM3A417 <br />