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STATE OF CAUFORrBA e� <br /> STATE WATER RESOURCES CONTROL BOARD ;49 6 <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY O t NEW PERMIT 0 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM Q 2 INTERIM PERMIT [ _� 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Chevron Station # Z o t3,�s 3 Aew L o N <br /> ADDRESS NEAREST CROSS STREET PARCELSPT AL) <br /> - <br /> CITY NAME STATE ZIP CQOE SITE PHONE a WITH AREA CODE <br /> CA 20 - io(.-ziFsi <br /> ✓ fOX <br /> ICA CORPORATION Q INDIVIDUAL =PARTNERSHIP EDLOCAL-AGENCYQ COUNTY-AGENCY' STATE-AGENCY' [=1 FEDERAL-AGENCY' <br /> TO INDICATE DISTRICTS' <br /> If 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 t GAS STATION 2 DISTRIBUTORQ ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.D.a(optional) <br /> IF <br /> Q 3 FARM Q 4 PROCESSOR = 5 OTHER OR TRUST LANDS �} <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> (L�� <br /> NAME(LAST,FIRST) PHONE•WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE•WITH AREA CODE <br /> 51 • 44 BI a n 0 -4Z -�Ls <br /> TS: NA E(LAST,FfIST) PHONE 0 WITH AREA CO E NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> e k to -1:vA-T of I 24 h <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> M NG OR ST ET ADDRESS ✓box b indicate 0 INDIVIDUAL E�j LOCAL-AGENCY STATE-AGENCY <br /> x O toy, 1 CORPORATION =PARTNERSHIP 0 COUNTY-AGENCY (] FEDERAL-AGENCY <br /> CI NAME �—� TATE, ZI�O � <br /> E � PHONE+1 WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) /`'.lW, C.� <br /> NAME OF OWNER Chevron U.S.A. Products Company CARE OF ADD E SINFOR O <br /> r� ff IS <br /> MAILING OR STREET ADDRESS P.O. Box 5004 ✓ box Ib indite INDIVIDUAL O LOCAL-AGENCY =STATE-AGENCY <br /> CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME San Ramon STAT^ ZIP CODE 94583 PHONE#WITH AREA CODE <br /> f-1 L4 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ [4_74- -10 131119 11131 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bfndicate t SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT O 6 EXEMPTION 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: I.ED II.Q Ill.X <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> OWNER'S NAME(PRINTED&SIGNED) OWNER'S TITLE DATE M TWDAY/Y R <br /> r aAlw �l ig-ss <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION FACILrTY*CJD g5-x/7 <br /> m ❑� I a 3 1A 15 3 `� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT x -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL p p <br /> 1 1� <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF MATION ONLY. <br /> OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROWORAGE TANK REGULATIONS <br /> FORMA(3/93) <br /> FOR0043A-R7 <br />