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D PROGRAM CONSOLIDATED FO A <br /> PRESUBMITTAL "1 TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY oj�Xb/I I b <br /> (one page per site) Page I of I <br /> TYPE OF ACTION ® 1.NEW SITE PERMIT (:13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TA REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/ SITE INFORMATION <br /> BUSINESS NAME(Sn wFACMFrYNAMaor DRA-Doinga®in=As) 3 FACILITY IDp 0 0 0 0 0 0 0 0 0 0 0 1 <br /> Chevron Station#210997 1r V vq 1 g <br /> NEAREST CROSS STREET 1 Ol{ O F( D K�w� 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> Hwy 99&Colony Drive,Ripon CA 95366 {L ay, ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION 3.FARM U 5. COMM CIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 40.3 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facilityon Indian Reservation or *Ifovmer of UST is a public agency:name of supervisor of division,secfion 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 /> H. PROPERTY OWNER INFORMATION <br /> PROPERTYOWNERNAME eo3 PHONE 409 <br /> Chevron Products Company, Attn: Permit Desk 925-842-9002 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O.Box 6004 <br /> CITY 410 STATE <br /> 411 ZIP CODE 412 <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE E 1.CORPORATION ❑2.INDIVIDUAL Ll4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414 PHONE 415 <br /> Chevron Products Company, Attn:Permit Desk 925-842-9002 <br /> 416 <br /> MAILING OR STREET ADDRESS <br /> P.O.Box 6004 <br /> CITY 417 STATE 41a ZIP CODE 419 <br /> San Ramon CA 94583 <br /> TANK OWNER inina: E 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY azo <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 1 3 1 1 9 1 3 Call(916)322-9669 if questions arise a21 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) E 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.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 notlfscations and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is We and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 624 PHONE 4zs <br /> D. R. LERI 4/16/02 925-842-9064 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 421 <br /> Chevron Products Company/D.R. LERI Retail ESH Specialist <br /> STATE UST FACILITY NUMBER(For local use only) 429 1998 UPGRADE CERTIFICATE NUMBER(For local use Duly) 429 <br />