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`bou- e <br /> STATE OF CAUFORNIA <br /> V <br /> STATE WATER RESOURCES CONTROL BOARD ; ' <br /> m 42�. e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> C MPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM F__1 2 INTERIM PERMIT V4 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 /> e�A"Y-o- tF 14 Z 75 SGLa.tro Fe [}VSA <br /> ADDRESS -q IN- NEAREST CR ST ET PARCEL#(OPTIONAL) <br /> 0 411, <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 1! CA GS7c,7 7$I/ BOX <br /> - SSSS <br /> TO INDICATE CORPORATION INDIVIDUAL PARTNERSHIP Q LOCAL-AGENCY ED COUNTY-AGENCY' 0 STATE-AGENCYFEDERAL-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 0 2 DISTRIBUTOR = RESER IND <br /> IAN #OF 7 qITE E.P.A. I.D.s(optional) <br /> 3 FARM 0 4 PROCESSOR 0 5 OTHER OR TRUST LANDS (—A L-0 oOO ZQ(p G <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> [}bvt $iAGv, 201 - 47ti3- I-A-J ,'v.,A ;Lo,) - 4 7 s! t;ge- <br /> NIGHTS: NAME(LAST FIRST) PHONE#WITH AREA CODE NIGHTS: 14AME ILAST,FIRST) PHONE#WITH AREA CODE <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 lo indicate INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 5004 ®CORPORATION PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CIN 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 ADfR�SS INFORMATION <br /> CHEVRON USA PRODUCTS CO. <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL (]LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 5004 EA CORPORATION O PARTNERSHIP (]COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SAN RAMON, I CA 94583 (510) 842-9500 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO <br /> F41 4-1-1 01 31 11 9 1 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box b indicate 1X 1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTEROFCREDIT Q 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: 1.= Il.[--1 III.E3 <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 MONTWDAY/YFJ1R <br /> KATHY NORRIS <. �CY✓(�S MKTG ASST — I L � 3 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OP� L CENSUS TR&QT# -OP L ("j SUPV --DISTRICT OQDE -PTIOi <br /> THIS FORM MUST BE ACCOMPANIED BY ATL ST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OFVVE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK <br /> FORMA("3) 0 FOROOD3A-R7 <br />