COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

Home Browse Search

9 ou.ces 4r nt STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A [�:j COMPLETE THIS FORM FOR EACH FACILITY/SITE a Pi t MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION 7 PERMA Y CXGSCO. SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I CArn ITV/CITE INFORMATION & ADDRESS- (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR Chevron SS# 96171 Chevron Stations Inc. ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) 6633 Pacific Ave. Ben Holt Dr. PHONE # WITH AREA CODE CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE Stockton CA 95207 209-477-4115 ✓ BOX] CORPORATION INDIVIDUAL PARTNERSHIP LOCAL -AGENCY (] COUNTY-AGENCYSTATE-AGENCY' FEDERAL -AGENCY' TO INDICATE DISTRICTS ' # owner of UST is a public agency, complete the following: name of supervisor of division, section or office which operates the UST TYPE OF BUSINESS ® 1 GAS STATION ❑ 2 DISTRIBUTOR ✓ IF INDIAN i # OFTV77- A. I. D. # (optional) Q 3 FARM Q 4 PROCESSOR Q 5 OTHER RESERVATION OR TRUST LANDS x:xacar_curV rr%MTAPT PP041IM 1PINUARVI EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE 209-477-4115 DAYS: NAME (LAST, FIRST) Chevron Maintenance PHONE # WITH AREA CODE 800-423-3528 Castro, Angie 0 CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE Castro, Angie 209-469-3520 Chevron Maintenance 800-423-3528 II PRnPFRTV OWNER INFDRMATIDN - (MUST BE COMPLETED) NAMEI,incoln Properties LTD CARE OF ADDRESS INFORMATION MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL -AGENCY O STATE -AGENCY 374 Lincoln Center 0 CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE Stockton I CA 1 95207 STATE m TAmv AV mco IAIrnCll#ATInM - IMI ICT RF rnMPI FTFD) NAME OF OWNER F CARE OF AA e RE l Chevron Products Co. t Ue S KON MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL (] LOCAL -AGENCY 0 STATE -AGENCY P.O. BOX 6004 [n CORPORATION 0 PARTNERSHIP (] COUNTY -AGENCY 0 FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE San Ramon CA 94583 510-842-9002 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 It questions arise. TY (TK) HQ F474--] 16'1'13 1119 111 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND 0 5 LETTER OF CREDIT 0 6 EXEMPTION [::] 7 STATE FUND 0 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER 0 9 STATE FUND & CERTIFICATE OF DEPOSIT O 10 LOCAL GOVT. MECHANISM 0 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. ICHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ it. ❑ III. ❑ I THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT COUNTY It JURISDICTION # FACILITY # G✓ ,bl� LOCATION CODE -OPTIONAL CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION -FORM B, UNLESS I HIS IS A UMANUt Ur JI it mrvmmh i ivri vvi - OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (6-95)