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M STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD , UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE to MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT [:] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED.SITE ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT E::] 6 TEMPORARY SITE CLOSURE a < 1. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME r� NAM OF OPERATOR CHEVRON STATION 4/ Z� t L 'a_o � � "IS AJ(I., ADDRESS19 l NEAREST CROSS STREET PARCEL#(OPTIONAL) CITY NAM STATE ZIP CODE SITE PHONE#WITH AREA CODE CA X7 60 2Da-SS-0 °70 ✓BOX CORPORATION INDIVIDUAL PARTNERSHIP a LOCAL-AGENCY ED COUNTY-AGENCY' 0 STATE-AGENCY' Q FEDERAL-AGENCY' TO INDICATE DISTRICTS #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 PUq 1 GAS STATION Q 2 DISTRIBUTOR 0 RESERVATION1IIF INDIAN #OF TANKS AT SITE E.P.A. 1.D.#(optional) Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS Z (-�f LWO EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE j1/J/� ✓ 9,A 2iq-9-1070'-VAC> CHEVRON MAINTENANCE 800-423-3528 NIGHTS: NAME(LAST,FIRST) PHONE#WITH 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 INFORMATIQL ��4GIF►('. ouarE -T�c 11 SrEPN&A2) MAILING OR STREET ADDRESS ✓ bcx to rrdca'e NDIVIDUAL EDLOCAL-AGENCYa STATE-AGENCY O -$d X 3C)GO O CORPORATION = PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CITY IJAMESTATE ZIP CODE PHONE#WITH AREA CODE alo eT _'f;& C.j+ QZ susq gig- Ill. -III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION CHEVRON PRODUCTS COMPANY PERMIT DESK MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY P.O. BOX 6004 )i CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE SAN RAMON CA 94583 925-842-9002 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. TY(TK) HQ F414-1_10 3 1 1 9 1 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓box to indicate 1 SELF-INSURED = 2 GUARANTEE =3 INSURANCE 0 4 SURETY BOND =5 LETTER OF CREDIT =6 EXEMPTION i)7 STATE FUND 8 STATE FUND b CHIEF FINANCIAL OFFICER LETTER =9 STATE FUND 8 CERTIFICATE OF DEPOSIT = 10 LOCAL GOVT.MECHANISM 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.0 if.[:] 111. 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 8 SIGNATURE) TANK OWNER'S TITLE DATE MONTHIDAYNEAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 7q 3 S mp I P o D LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL I 7 Iq 61 THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE IN RMATION ONLY. OWNER MUST FILE THIS F0PW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRVOSTORAGE TANK REGULATIONS FORMA(6-95)