Laserfiche WebLink
t , <br /> f: <br /> v <br /> STATE OF CAUFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 0 t NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION O 7 PER D SITE <br /> ONE REM F__j 2 INTERIM PERMIT 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME jq NAME OF OPERATOR <br /> Chevron Station # 2.v \-I �C\ <br /> ADDRESS NEAREST CROSS STREET PARCEL at(OPr10 <br /> CITY NAME STATE ZIP,CODE` SITE PHONE# AREA CODE <br /> GY1�N�� CA ` i hoc . ` c <br /> ✓ lx)X CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY <br /> TOINDIOX DISTRICTS' 0 COUNTY-AGENCY' STATE-AGENCYFEf NAI AGENCY' <br /> If owner of UST Is a pudic agency,complete the following:name of Supervisor of division,section,or office which operates the UST <br /> TYPE OF BUSINESSISI t GAS STATION 0 2 DISTRIBUTOR RESV IF <br /> ERVATDION x OF T AT SITE E.P.A. I.D.+e(optional) <br /> 0 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> NAME(LA T,,R,II�S PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> .� LA ISS Ur Mc.�f � <br /> S: NAME(LAS ,FIRS PHONE#WITH AREA CODE NIGHTS:NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> �`+ Vc� 1 2'1t4-`6q,!5 3��5 <br /> It. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> )CjNAM CARE OF ADDRESS INFORMATION <br /> MAILING OR STREET A71ESS ✓ box to indicate F__1 INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> }� )D H CORPORATION = PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CRYNAME Sr�1 ZIP CODEr PHONE#WITH AREA CODE <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CAREF DDR S INFORMA 10 <br /> Chevron U.S.A. Products Company D <br /> MAILING OR STREET ADDRESS ✓box b indicate INDIVIDUAL = LOCAL-AGENCY = STATE-AGENCY <br /> P.O. Box 5004 CORPORATION E::] PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME San Ramon STATE I ZIP CODE PHONE X WITH AREA CODE <br /> CA 94583 i ' �i�t�� C4 U�► <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HQ F41_4-]-10 1311 9 1 3 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓box bindicate 0<1 SELF-INSURED ED 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> = 5 LETTER OF CREDIT O 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 ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= II.E] 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 8 SIGNED) OWNER'S TITLE DATE )ONITH"D YNEAR <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT• -OPTIONAL SUPVISOR-DISTRICT CODE -OP17ONAL <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 FC&ITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGIf D STORAGE TANK REGULATICia <br /> FOR=3A-A7 <br />