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0 • <br />STATE OF CALIFORNIA Ap <br />s <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A s <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE t� <br />MARK ONLY 1 NEW PERMIT E] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PER ANEN CLOSED, SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) VVV <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />CHEVRON STATION // 1"7 <br />C+" *4SVt0jZj 45r*j A:,`, <br />ADDRESS <br />-& Pil,I F � . &6 <br />NEAREST CROSS STREET <br />Oe ur- <br />PARCEL # (OPTIONAL) <br />CITY NAME <br />STATE ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />'r01� <br />CA <br />CHEVRON EMERGENCY <br />be BOX EXCORPORATION 0 INDIVIDUAL 0 PARTNERSHIP 0 LOCAL -AGENCY 0 COUNTY -AGENCY' 0 STATE -AGENCY' 0 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 ® 1 GAS STATION 0 2 DISTRIBUTOR <br />✓ IF INDIAN <br />1# OF TANKS AT SITE <br />E. P. A. I. D. It (optional) <br />0 3 FARM 0 4 PROCESSOR 0 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />(�()�(�Q'Z (a S <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAY : NAME (LAST, FIRST) <br />PHONE # WITH AREA <br />�1 <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />ti -CODE <br />1L=o <br />2o-u"7-7-i-7��t <br />CHEVRON MAINTENANCE <br />800-423-3528 <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE It WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />CHEVRON EMERGENCY <br />INFO 800-231-0623 <br />CHEVRON EMERGENCY INFO <br />800-231-0623 <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />Q-0 <br />CARE OF ADDRESS INFORMATION <br />LIgV(zL_4 P&e_nC-& few <br />CHEVRON PRODUCTS COMPANY <br />MAILING O <br />STREET ADDRESS <br />✓ box to indicate 0 INDIVIDUAL 0 LOCAL -AGENCY 0 STATE -AGENCY <br />l <br />Lim"" N"li-.� C:I� vr <br />., <br />0 CORPORATION (] PARTNERSHIP � COUNTY -AGENCY � FEDERAL -AGENCY <br />CITY N<AM��� \ <br />STATE <br />ZIP CODE 7 <br />PHONE #WITH AREA CODE <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />DATE MM THI AYNEAR <br />CHEVRON PRODUCTS COMPANY <br />PERMIT DESK <br />MAILING OR STREET ADDRESS <br />✓ boxto indicate 0 INDIVIDUAL <br />LOCAL -AGENCY 0 STATE -AGENCY <br />P.O. BOX 6004 <br />EMORPORATION PARTNERSHIP <br />COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />SAN RAMON <br />CA <br />94583 <br />1510-842-9002 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ 44- -1 0 13 1 1 1= <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 7 STATE FUND <br />D 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND & CERTIFICATE OF DEPOSIT 0 10 LOCAL GOVT. MECHANISM 0 99 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br />ICHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. = it. [—] III. <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />TANK O,F^W`\NER'S NAME (QRINTED & SIGNATURE) <br />TANK OWNER'S TITLE <br />r <br />DATE MM THI AYNEAR <br />y� <br />y/vJ <br />� � •,moi <br />LOCAL AGENCY USE ONLY JIF r <br />COUNTY # JURISDICTION # FACILITY # <br />m VI /j. <br />LOCATION CODE - OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <br />THIS FORM MUST BE ACCOMPANIED BY AT MT (1) OR MORE PERMIT APPLICATION - FORM 8, UNLESAIS IS A CHANGE OF SITE INFORMATION ONLY. <br />FORMA (6-95) OWNER MUST FILE THIS FORIV THE LOCAL AGENCY IMPLEMENTING THE UNDERGRCWTORAGE TANK REGULATIONS <br />