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to <br /> STATE OF CALIFORNIA <br /> (o STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION' FOR�I��t�c���`�R��'�v�: <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> n <br /> MARK ONLY t NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOS <br /> MARK <br /> ONE REM Q 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE o <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAMEF OPERATOR <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> -\n Z)l— L <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA I CIS33 40 09-%'jL5_Cj <br /> TO DIICCATE CORPORATION Q INDIVIDUAL =PARTNERSHIP (] LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY' <br /> DISTRICTS' <br /> If 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 t GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN l#OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS Com' L OO O ( 17I <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PW&WTW AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 0 _ OI.. Sf --71-L--14 I <br /> NIGHT NAME(I ST,FIRST) PHONE If WITH AREA DEE 144 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) �J��a c�n�., <br /> NAME CARE OF ADDRESS INFORMATION <br /> CHEVRON USA PRODUCTS CO. <br /> MAILING OR STREET ADDRESS ✓box blndicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 5004 CORPORATION Q PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SAN RAMON, I CA 94583 (510) 842-9500 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> CHEVRON USA PRODUCTS CO. � <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 5004 ]CORPORATION PARTNERSHIP Q COuNrY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SAN RAMON, CA 94583 (510) 842-9500 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQM44- - 0 3 1119 1 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to Indicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT O 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.= if.[::] 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 MONTH/DAYNEAR <br /> KATHY NORRIS MKTG ASST <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m FFFI I I I I � <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 INF MATION ONLY. <br /> OWNER MUST FILE THIS FORM ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORMA(3/93) � a FOR0033A-R7 <br />