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UNIFIED PROGRAM CONSOLIDATED FOR.- " <br /> TANKS <br /> UST Facility <br /> 1 1 <br /> Page <br /> MARK ONLY El1 NEW PERMIT ❑3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION El7 PERMANENTLY CLOSED SITE 400 0l <br /> ONE ITEM [12 INTERIM ❑4 AMENDED PERMIT ❑ 6TEMPORARY SITE CLOSURE <br /> PERMIT <br /> I. FACILITY I SITE INFORMATION <br /> DBA OR FACILITY NAME 3 FACILITY ID 1 <br /> Chevron#90557 006437 <br /> STATE UST FACILITY NUMBER 401 _BOX TO INDICATE OWNER TYPE ❑4 LOCAL AGENCY/DISTRICT <br /> 000000 ®1 CORPORATION <br /> NEAREST CROSS STREET 402 E]2 INDIVIDUAL E]5 COUNTY AGENCY' <br /> ❑6 STATE AGENCW <br /> 139 S. Center St ❑3 PARTNERSHIP <br /> ❑7 FEDERAL AGENCY' 403 <br /> 1996 UPGRADE CERTIFICATE NO. 404 'K owner of UST a public 405 <br /> agency:name of supervisor of <br /> CA02118 division,section or office which <br /> operates the UST <br /> BUSINESS TYPE ®1 GAS STATION ❑3 FARM ❑5 OTHER ❑ IF Indian Reservation or trust land.407 TOTAL NUMBER OF TANKS AT SITE 406 <br /> 406 ❑2 DISTRIBUTOR ❑4 PROCESSOR <br /> 4 <br /> UST FACILITY <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 409 <br /> Greyhound Lines Inc. <br /> MAILING OR STREET ADDRESS 410 PROPERTY OWNER TYPE BOX TO INDICATE 411 <br /> ®1 CORPORATION ❑3 PARTNERSHIP <br /> P.O. Box 98110 ❑21NDNIDUAL ❑4 LOCAL AGENCY/DISTRICT <br /> NE# 415 <br /> CITY NAME 412 STATE 413 ZIP 410 PHO <br /> Louisville Ky 40298 <br /> III.TANK OWNER INFORMATION <br /> NAME 416 PHONE 417 <br /> Chevron Products Company attn: Permit Desk 925-842-9002 <br /> ADDRESS 418 TANKOWNERTYPE BOX TO INDICATE <br /> P.O. Box 6004 ®1 CORPORATION 4LOCAL AGENCY/DISTRICT 419 <br /> ❑2 INDIVIDUAL ❑ 5 COUNTY AGENCY <br /> E] 6STATE AGENCY <br /> ❑3 PARTNERSHIP <br /> 6001 Bollinger Canyon ROydd ❑ 7 FEDERAL AGENCY <br /> CITY 920 STATE 421 ZIP 422 <br /> San Ramon CA 94583-0904 <br /> TY(TK)HO 4 1 4 - 0 3 1 1 9 1 1 3 Call(916)322-9669 if questions arise 423 <br /> BOX TO ® 1 SELF-INSURED ❑4 SURETY BOND ❑7 STATE FUND ❑10 LOCAL GOVT MECHANISM <br /> INDICATE ❑ 2GUARANTEE <br /> ❑ 5 LETTER OF CREDIT ❑ 8 STATE FUND 8 CFO LETTER ❑990THER: <br /> ❑31NSURANCE ❑ 6 EXEMPTION ❑ 9 STATE FUND 8 CD 424 <br /> Legal not cation and mailing will be sent to the tank owner unless box 1 or 2 is checked: Check one box to ® 3 TANK OWNER 425 <br /> indicate which address should be used for legal notifications and mailing ❑ 1 FACILITY ❑ 2 PROPERTY OWNER <br /> I certify that the information provided herein Is true 8 accurate to the best of my knowledge <br /> APPLICANTS NAME PRINTED AND SIGNED 426 APPLICANT'S TITLE 427 1 DATE 428 <br /> Diane Leri Retail ESH 8/13/99 <br /> (Formerly SWRCB Form A) 139 <br />