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1 1} y y <br /> 4 _ .. <br /> STATEOFCALIFORNA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY D t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT `, a 8 #MPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OP401EIRATIOR <br /> Chevron.., tation #. 2.0;t1:0d.3. Aew, <br /> ADDRESS NEAREST,CR94S STREET, PARCEL# <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE`s <br /> -- -<_ CA X37 z oq. -3 t". <br /> ✓ BOx CORPORATION Q INDIVIDUAL Q PARTNERSHIP (] LOCAL-AGENCY [71COUNrY-AGENCY' E::] STATE-AGENCY' I EDERAL-AGENCY' <br /> TO INDICATE DLSTRICTS' <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 IQI f GAS STATION 0 2 DISTRIBUTOR / <br /> IF INDIAN INOF TANKS AT SITE E.=P.A. L D.#(optlonal) <br /> Jul IF <br /> 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> AYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE +'DAYS:NAME(LAST,FIRST): PHONE#WITH AREXCODE <br /> S►1V e S10 (4 -5Blg E'_ (N ,o4en n d y Z' 3Sa� <br /> NI TS: NAME(LAST,F ST) PHONE#WITH AREA COEX NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> M NG OR S ET ADDRESS ✓ box b indicate INDIVIDUAL = LOCAL-AGENCY =STATE-AGENCY <br /> rz) 5—CIZ LA CORPORATION PARTNERSHIP = COUNTY-AGENCY = FEDERAL-AGENCY <br /> TATE, ZI,..QOVEPHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) �( T <br /> NAME OF OWNER CAR A ADDRE INFOR 10 <br /> Cheyron U.S.A. Products Company ` r S <br /> MAILING OR STREET ADDRESS ✓box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 5004 <CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> :CITY NAME San Ramon STATE ZIP CODE 94583 PHONE#WITH AREA <br /> �CODE <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - 0 131119 11131 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to Indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE (]4 SURETY BOND <br /> CI 5 LETTER OF CREDIT 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 /> CHECK ONE BOX INDICATING WHICH ABOVEADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: <br /> TN,(S FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,1S TRUE AND CORRECT <br /> OWNER'S (PRINTED&SIGNED) OWNER'S TITLE DATE M TWDAYIYEAR <br /> : A-Ss <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m � n <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 /> FORMA(3/93) <br /> OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGRCTORAGE TANK REGULATIONS <br /> FOR0033A-R7 <br />