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UqDED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page 1 of I <br /> TYPE OF ACTION ® 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> i Chuck one item only) [14.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 4W <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sameas FACWTYNAM14lior DBA-Doing Business As) 3 FACILITYIDk 1 0 0 0 0 0 0 0 0 0 0 0 1 <br /> Chevron Station#210997 <br /> NEAREST CROSS STREET Oat FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> 1442 A Colony Drive,Ripon 95366 E 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS E 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *Ifowner of UST is a public agency:name ofsupervisorofdivision,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 2 ❑ Yes E No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <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 411 ZIP CODE 412 <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE E 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> [13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME 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 417 1 STATE 418 ZIP CODE 419 <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE 1.CORPORATION El 2.INDIVIDUAL ❑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- 1 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) E 1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> [12.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER* <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.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 lank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> CMification-1 certify that the informati ro herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPL DATE 424 1 PHONE 425 <br /> (D.R. LrE12I April 24,2003 925-842-9064 <br /> NAME OF APPLIC (p'(pW 426 TITLE OF APPLICANT 427 <br /> Chevron Products Company/Dr.R.LERI Retail ESH Specialist <br /> STATE UST FACILITY NUMBER(For local use only) 418 1998 UPGRADE CERTIFICATE NUMBER(For bcelmeonly) 429 <br /> UPCF(1/99 revised) 171 Formerly SWRCB Form A <br />