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• a <br /> STATEOFCAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK RfrIT `� - FORM A <br /> COMPLETE THIS FORM FOR i AciiiACILITYT n <br /> MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT r CTH E Fi f RM TION ❑ 7 PERMANENTLYSED SITE <br /> ONE REM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT B TEMPORARY SITE CLOSURE ,J/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ren \arc vCC k <br /> ADDRESSNEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1 S�v f`k0_.n J'f M,lSsIQ rl <br /> CITY NAME STATE ZIP DE SITE PHONE#WITH AREA CODE <br /> 1�o�leci� CA 3 a© < z -�(-1 <br /> Box TO INDICATE 1�CORPORATION F-1 INDIVIDUAL =PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY' Q STATE-AGENCY' (]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 1 GAS STATION 2 DISTRIBUTOR Q ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAV NAu 11 JIT 19=1 <br /> IRS PHONE#WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE <br /> Bob 77a-�4�� <br /> NIGHT ME LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 1 <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> CHEVRON USA PRODUCTS CO. <br /> MAILING OR STREET ADDRESS ✓box b Indicate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> P.O. BOX 5004 XO CORPORATION PARTNERSHIP Q COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SAN RAMON, CA P4583 (510) 842-9500 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CAE F ADDRESS INFORMATIN <br /> CHEVRON USA PRODUCTS CO <br /> MAILING OR STREET ADDRESS ✓box to indicate 1= INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 5004 X=CORPORATION 0 PARTNERSHIP COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SAN RAMON, CA 4583 (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- - 3 1 9 1� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate I] 1 SELF-INSURED F__1 2 GUARANTEE F-1 3 INSURANCE (]4 SURETY BOND <br /> E::]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 DATE MONTH/DAY/YEAR <br /> KATHY NORRIS MKTG ASST <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY#f <br /> 51al z <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DIS <br /> E7 27 <br /> :- C) / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGUL\7 <br /> FORM A(3A33) ` t`'``)1/ FOROM3MR7 <br />