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60UR ES STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD 3 UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FPWM FACILITY/SITE MARK ONLY 0 1 NEW PERMIT F7] 3 RENEWAL PERMIT CHANGE;OF INFORMATION n 7 PERMANENTLY CLOS ONE ITEM n 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 C.he',r roan _ 1 0 k e Rz'-t' ADDRESS . NEAREST CROSS STREET PARCEL#(OPTIONAL) P-o c 01 CITY NAME ST TE ZIP CODE SITE PHONE#WITH AREA CODE S vOCI� n CA _ 2011 - ✓ BOX TO INDICATE CORPORATIONIN IVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS1 GAS STATION 2 DISTRIBUTOR R SEIF RVATDION #OF TANKS T ITE E.P.A. I.D.#(optional) 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS C d 00'z EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional D NAME(LAST,�ST) PHONE WITH AREA CODE DAY : NAME(LAST,FIRST) (�l� z O.IC'AIt� its 20g 4-1-4115 QY\e4l OXI �S J NIGHTS: NAME(LAST,FIRST) PHON #'WITH AREA CODE NIGHTS: NAME(LAST,FIRST) #WITH AREA(PHONE `t <$oo 3 It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box toindicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY L_f,��In 8-CORPORATION (� PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Octd III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE ESS INEOR DDRA CHEVRON USA INC. L MAILING OR STREET ADDRESS- box toindicate 0 INDIVIDUAL LOCAL-AGENCY (� STATE-AGENCY P.O. BOX oO — CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE SAN RAMON I CA 94583 (510) 842-9002 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ L4 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE C PLETED)-IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED p 2 GUARANTEE = 3 INSURANCE C 4 SURETY BOND 5 LETTER OF CREDIT ° J' / [::]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.[–] II.D II THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT /�c APPLICANT'S NAME(PRINTED 8 SIGNAT E) APPLICANTS TITLE DATE MONTH/DAY/Y EAR KATHY L. NORRIS MKTG. AST. I� l LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 3 LOCATION COD€-IPTIONAL I CENSUU&TRAC'# -OPTIONAL SUPVISOR-DISTRICT COD -OPTNAL THIS FORM MUST BE ACCOMPANIED BY AAT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLEhS THIS IS A CHANGE OF SITE INFORMATION ONLY. G� - FORM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS I • ` ^ 3A- 6 �