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` � �SUURCFS <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD a c <br /> UNDERGROUND STORAGE TANK PERMIT APPLIC A <br /> o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F7 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERp70R <br /> u0 1(jt�� 1 reltl <br /> ADDRESS `t m NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> Lj ISO(j- 1�A-er('0t G <br /> CITY NAME <br /> Sky-- <br /> L�� STACA � SITE PHONEiQIITH AR tiODE <br /> J <br /> TINDBOX <br /> ICATE Q CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY _i Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ] I GAS STATION 0 2 DISTRIBUTOR q SERVATDION #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS tL <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) ��Q <br /> -1 .. e � 94 (I� R o (( rip <br /> NIGHTS: NAME PHONOE# IT �7 j1�! NIGHTS: NAME(LAST,F RST) OL 6 1 <br /> 3 7 S <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> NAM�1 v <br /> MAILING, OR STFRErE'T ADDRESS �3` box to indicate INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> C S `-t ��( tQV Q CORPORATION 9PARTNERSHIP QCOUNTY-AGENCY QFEDERAL-AGENCY <br /> CITY NAM STATE ZIP-r-0 t^ PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE DDRESS INFORM ION <br /> CHEVRON USA INC. e'_ ' �- <br /> MAILING OR STREET ADDRESS• ✓ box to indicate I Q INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 500 t]CORPORATION = PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> SAN RAMON CA 94583 (510) 842-9002 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ I4 4'j-I C) 7:j I_ 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate I SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> Q 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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 /> F <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNAjURE) APPLICANTS TITLE DATE +Mi TH/OAY EAR <br /> KATHY L. NORRIS \{,�J\ MKTG. AST. <br /> LOCAL AGENCY USE ONLY <br /> COUNTY It JURISDICTION# FACILITY# <br /> i I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL— SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(12-91) FILE THIS FORM WITH LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FOR0033A•R6 <br />