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• <br /> STATE OF CALIFORNIA 1 <br /> STATE WATER RESOURCES CONTROL BOARD W mom, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A , <br /> C MPLETE THIS FORM FOR EAC,CILITYISITE `�c,roRM•� <br /> MARK ONLY F7 1 NEW PERMIT3 RENEWAL PERMIT `J 5 CHANGE OF INFORMATION 7 PERM CLOS <br /> ONE REM 2 INTERIM PERMIT V4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE 7 �E[D) <br /> 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME V �+ ' ` NAME OF OPERATOR <br /> IJF q{ `t Z7S <br /> ADDRESS ` NEAREST CR ST ET PARCEL x(OPTIONAL) <br /> CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> Stb�-�C �-aK CA Zi.-7 4-7 8- Sss S <br /> TOINDI ATE Q CORPORATIONINDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY- Q STATE-AGENCY' Q FEDERAL-AGENCY' <br /> F 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 Is OF TANKS AT SITE E.P.A. 1.0.s(optima// <br /> ESERVATION <br /> 0 3 FARM 0 4 PROCESSOR 0 5 OTHER ORTR ST LANDS <br /> C.AL©o©Cz5to8C <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(L-AST,FIRST) PHONE s WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> 60 SiA� C.-, Z0 - ?S3 - ��SS tw 1?�>��cl 9 - 4-7$- SSS' " <br /> NIGHTS: NAME(LAST FIRST) PHONE s WITH AREA CODE NIGHTS: NAME tLAST.FIRST) PHONE a WITH AREA CODE <br /> at abs <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 ID Indicate 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 s 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 ADMSS INFORMATION <br /> CHEVRON USA PRODUCTS CO. L <br /> MAILING OR STREET ADDRESS ✓ box toindicam Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> P.O. BOX 5004 (CORPORATION Q PARTNERSHIP = COUNTY-AGENCY Q FEDERAL•AGENCY <br /> CITY NAME STATE ZIP CODE PHONE*WITH AREA CODE <br /> SAN RAMON, CA 1 94583 (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- -A 31 11 9 1 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓Dox b indicate UX 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> Q 5 LETTEROFCREOIT 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: I.= II.C 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 TITLEMONTWDAYNEAR <br /> DATE <br /> KATHY NORRIS �. �rwt 5 MKTG ASST G - 1`6 -73 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Ali <br /> LOCATION CODE •OP L CENSUS TR CTs -OP ` !� SUPVISO _ TRICT OPTAOi <br /> IJ � (fib <br /> THIS FORM MUST BE ACCOMPANIED BY ATL ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE moRMATION Y. \` <br /> FORMA(3193) <br /> OWNER MUST FILE THIS FORW � �THE LOCAL AGENCY IMPLEMENTING THE UNDERGRO ORAGE TANK - j10Hs �7\� <br /> � <br /> v <br />