COMPLIANCE INFO_1998-2006 - Laserfiche WebLink

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77,7"' L/ STATE OF CALIFORNIA �. �t5 ....., �O a STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE j MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMA Y ryas . SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS -(MUST BE COMPLETED) DBA OR FACILITY NAME Chevron SS# 96171 NAME OF OPERATOR Chevron Stations Inc. ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) 6633 Pacific Ave. Ben Bolt Dr. PHONE # WITH AREA COBE 800-423-352$ CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE Stockton CA 95207 209-477-4115 ✓ BOX] CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY' Q STATE -AGENCY' Q FEDERAL -AGENCY' TO INDICATE DISTRICTS ' If 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 r7l 1 GAS STATION ❑ 2 DISTRIBUTOR IF ❑ # OF TANKS AT SITE E. P. A. I. D. # (optional) Q 3 FARM a 4 PROCESSOR Q 5 OTHER RESER OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) Castro, Angie PH # WITH AREA CODE 20-7-4115 DAYS: NAME (LAST FIR T) Chevrontenance ODE 8E—SS NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA COBE 800-423-352$ Castro, Angie209-469-3520 PHONE # WITH AREA CODE Chevron Maintenance` ZIP CODE IL PROPERTY OWNER INFORMATION (MUST BE COMPLETED) '• NAMEq into n ,Properties LTA : CARE OF ADDRESS INFORMATION } MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL -AGENCY Q STATE -AGENCY 374 Lincoln Center Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE Stockton ZIP CODE 95207 PHONE # WITH AREA CODEy( III. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAMEAFeVLOn Products Co. CARE OF eDF1ES F YVATJON MAILING OR STREET ADDRESS ✓ boxtolindicatte22IlIl QJLJ IINDDIIV�IIDUAL Q LOCAL -AGENCY Q STATE -AGENCY P.O. BOX 6004 Q CORPORATION Q PARTNERSHIP Q COUNTY -AGENCY Q FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODEy( San Ramon. 510-842-9002 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ 4 4- - 3 19 1. 3 V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED ✓ box to indicate 0 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND iQ 5 LETTER OF CREDIT Q 6 EXEMPTION [-17 STATE FUND Q 8 STATE FUND & CHIEF FINANCIAL OFFICER LETTER Q 9 STATE FUND & CERTIFICATE OF DEPOSIT Q 10 LOCAL GOVT. MECHANISM Q 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. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ II. ❑ III. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT \NK OWNER'S NAME (PRINTED & SIGNAT RE) TANK OWNER'S TITLE DATE MgqNTHIDAYNEAR Kathy L Norris 7/ / mpliance M.A. 12/291' -OCAL AGENCY USE ONLY COUNTY # JURISDICTION # FACILITY # M lz'L�;l 77W r �v LOCATION CODE -OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LM(1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORM THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FORM A (6-95)