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P�6ou..T-s C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W 49 �a UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM AIR COMPLETE THIS FORM FOR EACH FACILITY/SITE 4CIPOKO" MARK ONLY 011 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑j 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED E ONE REM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR CK-12 Jr 0 V1 93Z32- (Z(cz_rjr, G,O��(eS ADDRESS ��O �� _ /'� NEAREST CROSS STREET PARCEL M(OPTIONAL)CITY NAME J��x/ STATEZIP CODE SITE PHONE#WITH AREA CODE CA �(�2-(0 •Zo - 1+77 - oc4-7 BOX TOINDIC TE I]CORPORATION INDIVIDUAL []PARTNERSHIP DISTRICTS ]COUNTY-AGENCY' E-1 STATE-AGENCY' El FEDERAL-AGENCY' If owner of UST Is a public agency,complete the following:name of Supervisor of division,section,or office which operates the UST TYPE OF BUSINESS [X 1 GAS STATION ❑ 2 DISTRIBUTOR0 RESEIF R INDIAN j*OF TANKS AT SITE E.P.A. I.D.#(optional) 0 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUST LANDS � Z9 6_78 1 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) 1 PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DJl2a�eS coo ?�9 - �F77- a�1�"7 �SC�r aS�s o �I - 4_77- o�Eqq-7NITS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: N E(LAS ,FIRST) PHONE#WITH AREA CODE C i- 'L0cj - 47 7- 346 �sca�r v �10�. �9 - iF-7 2- X11. PROPERTY OWNER INFORMATION- MUST BE COMPLETED _bIKME CARE OF ADDRESS INFORMATION CHEVRON USA PRODUCTS CO. MAILING OR STREET ADDRESS ✓ box bindicate INDIVIDUAL (] LOCAL-AGENCY [] STATE-AGENCY P.O. BOX 5004 [j CORPORATION ] PARTNERSHIP (]COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE# ITN AREA CODE SAN RAMON, CA 94583 (5103 842-9500 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF A ESS INFORMATION CHEVRON USA PRODUCTS CO. MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL (] LOCAL-AGENCY STATE-AGENCY P.O. BOX 5004 ®CORPORATION (] PARTNERSHIP ]COUNTY-AGENCY (] FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE SAN RAMON, CA 94583 (510) 842-9500 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. TY(TK) HQ 44- -I d 3 1 9 1 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓box b indicate 1 SELF-INSURED ]2 GUARANTEE I]3 INSURANCE ]4 SURETY BOND (]5 LETTER OF CREDIT I]6 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: L❑ Il.❑ Ill.❑( THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATEMONTH/DAYNEAR KATHY NORRIS /�� S MKTG ASST 4? - f 6 3 LOCAL AG NCY USE ONLY COUNTY# JURISDICTION# FACILITY# m FT-71 1z,151111 Lk� LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE-OPTIONAL 6-1-?t 7/ THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFOR MATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUN STORAGE TANK REGULATIONS FORMA(3193) FON9033M117 �I°L RIf