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STATEOFCAUFORWA �% <br /> STATE WATER RESOURCES CONTROL BOARD S <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORMA <br /> 9 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY k NEW PERMIT 3 RENEWAL PERMIT , 5 CHANGE OF INFORMATION 7.PE SITE <br /> ONE ITEM Q' 2i INTERIM PEwrr s. . ;T_� 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE ! <br /> I. FACILITY/SITE INFORMATION&ADDRESS (MUST BE COMPLETED) <br /> DBA OR FACILITY NAME"I' NAME OF OPERATOR <br /> Chevron Station #, ZO \-I �� 1 ? 1, S-b Cori i c�+nC, - <br /> M ADDRESS NEAREST CFAM STREET PARCEL#(OPFION <br /> CITY NAM STATE ZPC= SITE PHONE# ITH AREA CODE' <br /> ✓ BOX CORPORATION INDIVIDUAL PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AAENCY' f�STATE-AGENCY' FF�ERAL•AGENCY' <br /> TO INDICATE DISTRICTS' <br /> It 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 DISTRIBUTOR ✓ IF INDIAN Is OFT T SITE E.P.A. I.D.f(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR,..o S OTHF,R 05 TRUST UWDS <br /> E ERGENCYCONTACTPERSON (PRIMARY) EMERGENCY'CONTACT.PERSON (SECONDARY)-optional <br /> S. PHONE#WITH AREA Q ;DAYS-NAME(LAST,FIRST),(� PHONE r WITH AREA CODE <br /> J 17 (o vj, v n*V t a <br /> PHONE#WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE tt WITH AREA COD <br /> SVEfFr S142Z .1 �1 LS O-�a3- <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED) <br /> NAME+ CARE OF ADDRESS INFORMATION <br /> T. \ r r 8 6�)C� <br /> MAIL I OR TREET' f•SS ✓ boxbindicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> I ?�) V `J�('-f CORPORATION = PARTNERSHIP Q COUNTY-AGENCY FEDERAL-AGENCY <br /> CITYST ZIP E PHONE><WITH AREA CODE <br /> III. TANK OWNER INFORMATION•(MUST BE COMPLETED) <br /> NAME OF OWNER CARE pFADDRESS INFORMATIO <br /> Chevron U.S.A. Products Company - <br /> MAILING OR STREET ADDRESS P.O. BOX 5004 ✓box b indicate INDIVIDUAL (] LOCAL-AGENCY 0 STATE-AGENCY <br /> f ,P<CORPORATION E::] PARTNERSHIP O COUNTY-AGENCY C] FEDERAL-AGENCY <br /> CITY NAME San Ramon STATE I ZIP CODE 94583 PHONE#WITH AREA CODE <br /> CA 7 8 ,5 1 - iy -- C O CO- <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ M44- - 0 3 1 9 1 F31 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box bIndicate 0<1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> = 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: I.EJ II. III.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 DNTHID NEAR <br /> - NotaI M��6 A J,s4 1 1 11Z <br /> LOCAL XGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> mL� <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY A AST(1)OR MORE PERMIT APPLICATION' FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS Ft ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGO, <br /> D STORAGE TANK REGULATK)NS <br /> FORMA(3193) FOR0033A-R7 <br />