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�;ni°rs•-�.sago^^-�:-+�wq, �+�:e°S�gr4ayYq+titlry�'1'dr'ri-.,�- 'piJswr:+'�9r�xar-.,.."G^'^E"�"�1'iwi�..T=s+arw+ev++,�pr-g k '^'c^r,� .— <br /> #94275 <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD WP yl`° <br /> FORM 'A': <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/ TION 6 �0 <br /> ,- <br /> COMPLETE THIS FORM FOR EACqN'PI Clq*_C/O 1 1*lr— <br /> Fes/ <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANG FF/INFORMnATIIOeN n ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPRAAY SITZ AS 9plo t\ Q <br /> 1. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE CWwi§M C F_P� p p q <br /> AL HEALTH w <br /> FACILITY/SITE NAME CARE OFA D I A I <br /> Lincoln Village West Chevron <br /> ADDRESS NEAREST CROSS STREET ✓Boz to indicate 5 PARTNERSHIP ❑ STATE-AGENCY <br /> 2905 W. Benjamin Holt Plymouth Road ❑ NORPORATION El El OUNTA LOCAL-AGENCY <br /> ElFEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Stockton CA 95207 209-478-5555 <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESERVATION N #of TANK, <br /> i GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS ❑ AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Felton, Sharon 209-478-5555 Paige, Ken 209-334-2241 <br /> I NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Felton, Sharon 209-369-1112 Paige, Ken 209-334-2241 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Chevron USA, Inc. <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> P.O. BOX 6004 ® CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCY <br /> J ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> San Ramon CA 94583 415-842-9050 <br /> III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Chevron USA, Inc. <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> P.O. Box 5004 IN CORPORATION ElLOCAL-AGENCY ElFEDERAL-AGENCY <br /> ., Cl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> San Ramon CA 94583 415-842-9050 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. [::] 7111,7771 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY RY,AN T THEM M KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> 1 G- a-at�1s1So13 1 4 -v24 —�;O <br /> r <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FA YID# #of TANKS at SITE <br /> [3:1 <br /> [PERMIT <br /> RENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE WITH AREA CODE <br /> NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> ATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED 2YES ❑ NO �CK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)ORM E TANK PERMIT FORM 'B'APPLICATION(S), UNLESS*S A CHANGE OF SITE INFORMATION ONLY. V <br /> FORMA(3-2-88) � <br /> DATA PROCESSING COPY Y� <br />