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6pOVq � <br /> �! <br /> STATE OF CALIFOPRA ,. <br /> r <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A ,� o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE °'�•oRN`' <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br /> ONE REM 0 2 INTERIM PERMIT u 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> Chevron Station # 7 1_ ,,,) <br /> ADDRESS `` NEAREST CROSS STREET PARCEL$ <br /> CITY NAME STATE ZIP CODESITE PHONE#WITH AREA CODE <br /> _ <br /> ✓BOX <br /> TO INDICATE CORPORATION INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY' STATE-AGENCY' 0 fEOERAL-AMNCY' <br /> 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 1 GAS STATION 2 DISTRIBUTOR 0 ✓ IF INDIAN 1#OF TANKS AT SITE I E.P.A. 1.D.a(optional) <br /> RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS C? <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> AYS:NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS:NAME(LAST,F ST) PHONE a WITH AREA COOE NIGHTS:NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> c; (� 1 -22 'i� ► y <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> -1 n � <br /> M OR STREET ADDRESS ^� ✓ box b Indicate 0 INDIVIDUAL Q LOCAL-AGENCY 0 STATE-AGENCY <br /> C) y \J v - CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> Crr11 NAME bTATE ZIP CODE PHONE a WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORION <br /> Chevron U.S.A. Products Company k 7x a Ir ir is <br /> MAILING OR STREET ADDRESS p O. Box 5004 ✓ Wx indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> r• ,CORPORATION = PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a WITH AREA CODE <br /> San Ramon CA 94583 _ . <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- -10 13111 CT[3] <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate �1 SELF-INSURED Q 2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 0 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: <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 HIDAY EAR <br /> �Jnr'ir K Y(,.t k (<-T <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION Ik FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -OPTIONAL SUPVISOR-DISTRICT CODE-OP77ONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESSTHIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FOR THE LOCAL AGENCY IMPLEMENTING THE UNDERGRSTORAGE TANK REGULATIONS <br /> FORMA(3J93) FOR0003A'R7 <br />