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UVD PROGRAM CONSOLIDATED FOR <br /> IJP o l <br /> UNDERGROUND STORAGE TANKS - FACILITY y1�1o3 <br /> (one page per site) Page of I ( <br /> TYPE OF ACTION ® 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERAUT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sameas FACn.MY NA or DBA-Iluing Business As) 3 FACILITYID# 1 O 1 0 _ O O O O O O O G 0 t <br /> Chevron Station#210997 9t <br /> NEAREST CROSS STREET 1640 F(01Cf6Src KO 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> 1442#Colony Drive,Ripon 95366 ® 1.CORPORATION ❑S.COUNTY AGENCY' <br /> BUSINESS ® 1.GAS STATION ❑3.FARM 0 5. COMMERCIAL ❑ 2.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY" 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 2 ❑ Yes ® No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 401 PHONE 406 <br /> Chevron Products Company, Attn:Permit Desk L2375 B-3 925-842-9002 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O.Box 6004 <br /> CITY 410 STATE Ott ZIP CODE 412 <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Chevron Products Company, Attn:Permit Desk L2375 B-3 925-842-9002 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O.Box 6004 <br /> CITY 4n STATE 418 ZIP CODE 419 <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE I.CORPORATION [12.INDIVIDUAL Ll 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 0 13 1 1 19 1 1 13 1 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 4M <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the informati o ' herein is no and accurate to the hest of my knowledge. <br /> SIGNATURE OF APPL DATE 424 PHONE 425 <br /> D.R. LrERI April 24,2003 925-842-9064 <br /> NAME OF APPLICANT(p' 426 TITLE OF APPLICANT 427 <br /> Chevron Products Company/ . .LERI Retail ESH Specialist <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For kalusconiy) 429 <br /> UPCF(1/99 revised) 171 Formerly SWRCB Form A <br />