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..HUD PROGRAM CONSOLIDATED F(,.,,,i 3.03 TANKS UNDERGROUND STORAGE TANKS - FACILITY 3W G TYPE OF ACTION ❑ 1.NEW SITE PERMIT (one page per site) Page 1 of I ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SrrE (Check one item only) ❑4.AMENDED PERMIT Specify chao )Mal use only X 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 L FACILITY/SITE INFORMATION BUS INESSNAME(sone®FACuslYNAMEWnRA_Donl1winm As) 3 FACILTfY 1Dq Chevron Station#90557 A 69/7& 3 0 0 0 0 0 0 0 0 0 0 0 1 NEAREST CROSS STREET All FACILITY OWNER TYPE 4.LOCAL GENCY/DISTRICT* 139 S.Center Street, Stockton CA 95202 ® 1.CORPORATION ❑5.COUNTY AGENCY' BUSINESS 1.GAS STATION 3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑&STATE AGENCY' TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER a°3 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* TOTAL NUMBER OF TANKS Is facility on Indian Reservation or "If owner ofUST is a public agency nonce of styervisor ofdiviaim,xctim or office wfiidt REMAINING AT SITE trusdands? operates the UST(This is the contact perste for the tank records.) 0 ❑ Yes ® No acs aoa IL PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 401 PHONE 4ca GREYHOUND LINES INC TREAS DEPT MAILING OR STREET ADDRESS 4� P.O.BOX 891932 CITY 410 1 STATE 411 ZIP CODE 412 DALLAS TX 75389 PROPERTY OWNER TYPE I.CORPORATION 2.INDI VH)UAL 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 Chevron Products Company, Attn:Permit Desk L2375 B-3 925-842-9002 MAILING OR STREET ADDRESS 416 P.O.Box 6004 CITY 417 1 STATE 418 1 ZIP CODE 419 San Raman CA 94583 TANK OWNER TYPE 1.CORPORATION 2.INDI VB)UAL El 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(17K)HQ 44- 1 0 13 1 1 1 9 1 1 13 1 Call 916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ® L SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM ❑2.GUARANTEE [15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER:_ [13.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD 4M VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal rmtificaims and mailings will be win to the tank owner udess box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423 VII.APPLICANT SIGNATURE Certification-I artily,that the informatlm provided herein is tme and accmah to the best of my knowledge. N TUI"F APPLICANT DATE 424 1 PHONE 425 /for Diane Leri 12/23/02 925-942-9064 AME OR APPLICANT(putt) aa6 TTTLE OF APPLICANT 4V Chevron Products Company ��iSD� c6 Retail ESH Specialist STATE UST FACILITY NUMBER(F«tical we only) 428 1998 UPGRADE CERTIFICATE NUMBER(Fcrkt use only) a19 I )