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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT El 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404- FACILITY ID It <br /> 2 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> Chevron Station#210997 <br /> BUSINESS SITE ADDRESS 103- CITY 104. <br /> 1442 A Colony Drive Ripon, CA 95366 <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME Out. PHONE 400. <br /> Chevron Products Company, Atm. HES Permit Desk L23,75 (925)842-9002 <br /> MAILING ADDRESS 409. <br /> P.O. Box 6004 <br /> CITY <br /> 410. STATE 411. . ZIP CODE 412. <br /> San Ramon CA 94583 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 428-. <br /> Chevron Products Company, Ann:HES Permit Desk L2 75 (925)842-9002 <br /> MAILING ADDRESS 428-3. <br /> P.O.Box 6004 <br /> CITY 420-4 STATE 428-5. ZIP CODE 428-6. <br /> San Ramon CA 94583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> Chevron Products Company, Attn:HES Permit Desk L2375 (925)842-9002 <br /> MAILING ADDRESS 416. <br /> P.O. Box 6004 <br /> CITY 411. STATE 418. ZIP CODE 419_ <br /> San Ramon CA 94583 <br /> OWNER TYPE: ® I.CORPORATION ❑ 2.COUNTY AGENCY ❑ 3.STATE AGENCY 420 <br /> ❑ 4.FEDERAL AGENCY ❑ 5.NON-GOVERNMENT ❑ 6.LOCAL AGENCYIDISTRICT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 131 1 J 911 1 3 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ L FACILITY OWNER ❑ 4.TANK OPERATOR 423. <br /> Z 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: I ertif that the information rovided herein is true,accurate,and in full compliance with legal re uirements. <br /> APPLICANT SIGNATU DATE 424, PHONE 425. <br /> 06/10/2009 925-842-9002 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 423 <br /> Chevron Products Com an IM HARTMAN Retail HES Permit Desk <br /> UPCF UST-A Rev.(12/2007) e completed <br />