COMPLIANCE INFO_1993-1998 - Laserfiche WebLink

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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD W dam, a UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT �5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED,SITE ONE ITEM ❑ 2 INTERIM PERMIT F-14 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ©t I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR CHEVRON STATION # ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE If WITH AREA CODE ✓BOX XR CORPORATION INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' 0 FEDERAL-AGENCY' TO INDICATE DISTRICTS If owner of UST is a public agency,complete the following:name of supervisor of division,section or office which operates the US-1 TYPE OF BUSINESS f—] 1 GAS STATION 2 DISTRIBUTOR ✓IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) RESERVATION Q 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE __:g ., CHEVRON MAINTENANCE 800-423-3528 NIGHTS: NAME(LAST,FIRS PHONE#WI AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE CHEVRON EMERGENCY INFO 800-231-0623 CHEVRON EMERGENCY INFO 800-231-0623 II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) NAM CARE OF ADDRESS INFORMATION TRAINI:r T- -AMS MAILING OR STREET ADDRESS ✓ box to indicate ED INDIVIDUAL LOCAL-AGENCY STATE-AGENCY d O CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME ST/A�TE,�, ZIP CODE PHONE#WITH AREA CODE ff W, III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION CHEVRON PRODUCTS COMPMY DESK MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY C] STATE-AGENCY P.O. BOX 6004 =CORPORATION 0 PARTNERSHIP COUNTY-AGENCY CI FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE If WITH AREA CODE SAN RAMON A 94583 510-842-9002 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ M44- - 0 3 1 119-TIN] V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED i ✓box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE E:j 4 SURETY BOND [:]5 LETTER OF CREDIT =6 EXEMPTION =7 STATE FUND 0 8 STATE FUND&CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND&CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM = 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. i CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT TANK OWNER'S NAME(PRINTED&SIG TUBE) TANK OWNER'S TITLE DATE MONTWDAYNEAR LOCAL AGENCY USE ONLY COUNTY 9 JURISDICTION# FACILITY# LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL i. THIS FORM MUST BE ACCOMPANIED BY AT AST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FOR H THE LOCAL AGENCY IMPLEMENTING THE UNDERGR STORAGE TANK REGULATIONS FORM A(6-95) 'F zt1�9r�