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i!. - '6pt1p STATE OF CAUFORNIA ,d c STATE WATER RESOURCES CONTROL BOARDW� 40 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY O I NEW PERMIT 3 RENEWAL PERMIT r 5 CHANGE OF INFORMATION D 7 PERMANENTLY CLOSED ONE REM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE;.. I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) r DBA OR FACILITY NAME NAME OF OPERATOR Qv 912s' i(_e-rdo Qartza,l2 ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) 0 CORPORATION = PARTNERSHIP (] COUNTY -AGENCY FEDERAL -AGENCY CITY NAME CITY NAME � r STATE ZIP CODE SITE PHONE N WITH AREA CODE --rC'bC.CC.` CA CS Zt o 2o`i - 47-7 7 I/ BOX TOINDICATE D CORPORATION] INDIVIDUAL = PARTNERSHIP Q LOCAL -AGENCY COUNTY-AGENCYSTATE-AGENCY' F__1 FEDERAL -AGENCY' DISTRICTS' 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 = 1 GAS STATION = 2 DISTRIBUTOR = ✓ IF INDIAN # OF TANKS AT SITE E. P. A. I. D. i (optional) FARM 4 PROCESSOR = 5 OTHER RESERVATION OR TRUST LANDS f (:A3 i ,(}p�296? tMLHGtNGY WN I AG I FtH5UN (FHIMAHY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE X WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE * WITH AREA CODE GI�A ale - q?'7- D` 4'7 ESCar t5a o 2.>9 - 4'7-7- Qjq7 NI S: NAME (LAST, FIRST) PHONE #t WITH AREA CODE NIGHTS: NAME (LAS , FIRST) PHONE # WITH AREA CODE e S Z , 2 c - 4 7 ;-- C 0" Zo? Z - -6 8 'T II.` PROPERTY OWNER INFORMATION - (MUST RE POMP[ FTFDI NAME CHEVRON USA PRODUCTS CO. CARE OF ADDRESS INFORMATION DATE MONTWDAYNEAR MAILING OR STREET ADDRESS ✓ box to Indicate = INDIVIDUAL LOCAL -AGENCY STATE -AGENCY P.O. BOX 5004 0 CORPORATION = PARTNERSHIP (] COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE CITY NAME PHOt4E XITH AREA CODE SAN RAMON, !A PHONE N WITH AREA CODE SAN RAMON, ((5101 842-9500 III. TANK OWNER INFORMATION -(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION DATE MONTWDAYNEAR CHEVRON USA PRODUCTS CO. "i, MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL -AGENCY STATE -AGENCY P.O. BOX 5004 Il CORPORATION = PARTNERSHIP COUNTY -AGENCY (] FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE SAN RAMON, 94663 (510) 842-9500 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ F414-] - 1j 91 11 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY- (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box b indicate 0 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE [] 4 SURETY BOND 5 LETTER OF CREDIT 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: I. F__1 Il. F__1 111. 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 DATE MONTWDAYNEAR KATHY NORRIS S LOCAL AGENCY U5t UNLY j U COUNTY # JURISDICTION # FACILITYt# //_ m� I tiI 4(/ LOCATION CODE - OPTIONAL CENSUS TRACT x - OPTIONAL SUPVISOR - DISTRICT CODE - OP77ONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM 8, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (3193) 0 0 FOR003M-R7