Laserfiche WebLink
F- , <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 10 5 CHANGE OF INFORMATION ❑ 7 PERMANEN CLOSED. SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT In 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />CHEVRON STATION # <br />G.V--ti AY-_, % <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL# (OPTIONAL) <br />49 Povu pie, <br />P Q - <br />PHONE # WITH AREA CODE <br />CI NAME <br />STATE ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />STATE <br />CA <br />-209?-477 �T <br />✓ BOX 9XCORPORATION INDIVIDUAL PARTNERSHIP LOCAL -AGENCY LI COUNTY -AGENCY' 0 STATE -AGENCY' Q FEDERAL -AGENCY' <br />TO INDICATE DISTRICTS <br />' 9 owner of UST is a public agency, complete the following: name of supervisor of division, section or office which operates the UST <br />TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR <br />✓ IF INDIAN <br />1# OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />Q 3 FARM 4 PROCESSOR = 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />I �( <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE' <br />MAILING OR STIk ET ADDRESS <br />CHEVRON MAINTENANCE 800-423-3528 <br />NI NAME ST, Fl T) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE ` <br />CHEVRON EMERGENCY INFO 8010-231-0623 <br />CHEVRON EMERGENCY INFO 800-231-0623 <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STIk ET ADDRESS <br />✓ box to indicate 0 INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY <br />PERMIT <br />= CORPORATION 0 PARTNERSHIP 0 COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CI1- (;AME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER A" <br />CARE OF ADDRESS INFORMATION <br />DATE MQNTFUDAYNEAR <br />CHEVRON PRODUCTS 6MPANY <br />PERMIT <br />MAILING OR STREET ADDRESS <br />✓ box to indicate 0 INDIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />P.O. $OX 6004 <br />('CORPORATION 0 PARTNERSHIP <br />0 COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />SAN RAXON <br />94583 <br />1510-842-9002 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ 4 4- - 0 3 1 3 <br />9 1 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate i 1 SELF-INSURED I1 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT = 6 EXEMPTION [___1 7 STATE FUND <br />0 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER = 9 STATE FUND & CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT. MECHANISM = 99 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1. ❑ It. ❑ 111. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK OWNER'S & SIGNATURE) <br />TANK OWNER'S TITLE <br />DATE MQNTFUDAYNEAR <br />aNAMENTED <br />r nnwr wn�-u nv rrne- nut v <br />LVVHL AL7CI1lii Uar-V11Li <br />COUNTY # JURISDICTION It FACILITY # <br />❑ FT—T-1~ <br />LOCATION CODE - OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <br />THIS FORM MUST BE ACCOMPANIED BY AT T (1) OR MORE PERMIT APPLICATION - FORM B, UNLESI&S IS A CHANGE OF SITE INFORMATION ONLY. <br />FORMA (6.95) <br />OWNER MUST FILE THIS FORMW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROWTORAGE TANK REGULATIONS <br />