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- #91452 <br /> STATE OF GALIORNIA WATER RESOURCES CONTROL BOARD yEa <br /> p 9 <br /> FORM 'A' <br /> 7AY 1 19Q0 UNDERGROUND STORAGE TANK P5MRAM <br /> %Tlr9)N LFFMl.ffdi, INFORMATION and/or PFRMIT APPLICATION <br /> PERMIT/SERVICES COMPLETE THIS FORM FOR EACHF ILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT X❑ *RENEWAL PERMIT Elr5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE tWrgl7 <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME <br /> CARE OF ADDRESS INFORMATION <br /> Bill Parks Chevron O <br /> ADDRESS NEAREST CROSS STREET ✓Ro,to imdule PARTNERSHIP 0 STATE AGENCY <br /> 334 East Main Street Hw 99 11CORPORATION 0 LOCAL-AGENCY 0 FBIERALAGENCY <br /> Y 11 INDIVIDUAL 0 COUNIY-AGENC( <br /> CITY NAME STATE ZIP CODE SITE PHONE N,WITH AREA CODE <br /> Ripon CA 95366 209-599-2313 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box 6INDIAN EPA ID # <br /> ® 1 GAS STATION ❑ 3 FARM ❑5 OTHER TRUSTVLANDS or ❑ ATTR S SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) <br /> DAYS: NAME(UST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE# EA WITH ARCODE <br /> Parks, Bill 209-599-2313 Parks, aren 209-599-2313 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME'LAST,FIRST) PHONE#WITH AREA CODE <br /> Parks, Bill 209-527-4258 Parks, aren 209-527-4258 <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Gwendolyn Scheffer Estate <br /> MAILING or STREET ADDRESS ✓Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> 444 Market Street, Suite 2200 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME - STATE ZIPCODE PHONE N,WITH AREA CODE <br /> San Francisco CA 1 94111 <br /> Ill. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Chevron USA, Inc. <br /> MAILING or STREET ADDRESS " Boz to indicate 0 PARTNERSHIP 0 STATE-AGENCY <br /> P.O. BOX ¢004 8 CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> J INDIVIDUAL 0 COUNTY-AGENCY <br /> CIN NAME STATED ZIP CODE PHONE#,WITH AREA CODE <br /> San Ramon CA 94583 415-842-9050 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS- <br /> CHECK <br /> DDRESS .CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ IL ❑ III. h❑' <br /> THIS FORM HAS BEEN COMPLETED UNDER PENAL PERJURY, TO THE T OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) _ DATE <br /> PAVIC> 6r. To _4S0 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# If of TANKS at SITE <br /> 6) o I / E 6 s a 1 o 10 1 1/ <br /> CURRENT LOCALAGENCY FACILITY ID N APPROVE BY NAME PHONE#WITH AREA CODE <br /> CSE vR 3 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BU NESS PLAN FILED DATE FILED <br /> 0 a CT <br /> 3 17 Q } f YES E] NO E] ! /j <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT if BY: T <br /> THIS FORM MUST BE ACCOMPANIED BY ATI�T(1)OR MORE TANK PERMIT FORM 'B'APPLICATIONI UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. , I <br /> FORM A(G 2-e8) <br /> DATA PROCESSING COPY <br />