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D PROGRAM CONSOLIDATED FORK <br /> PRESUBMITTAL (0 TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY oj�'L b/I 1 a <br /> (one page per site) Page I of 1 <br /> TYPE OF ACTION ® L NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑S.CHANGE OF INFORMATION <br /> ❑ 7.PERMANEMLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6-TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SM INFORMATION <br /> BUSINESS NAME(Smnem FACILITY NAME or DBA-Doing easiness As) T <br /> 0 Q 0 0 0 0 0 0 0 0 0 1 <br /> Chevron Station#210997 <br /> NEAREST CROSS STREET `pl� p �f Dk}w� FACILITY TYPE 4.LOCAL GENCY/DISTRICT* <br /> Hwy 99&Colony Drive,Ripon CA 95366 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS E 1.GAS STATION 3.FARM 5. C 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. O3.PARTNERSHIP ❑7.FEDERAL AGENCY* 492 <br /> TOTAL NUMBER OF TANKS Is facility on Indian ReseownerofUSTisapoblic agency:nameofsupesection or office which <br /> REMAINING AT SITE trustlands7rates 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 402PHONE 408 <br /> Chevron Products Company, Attn:Permit Desk 925-842-9002 <br /> MAILING OR STREET ADDRESS <br /> 409 <br /> P.O.Box 6004 <br /> CITY 410 1 STATE 411 ZIP CODE <br /> atx <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE E 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY CIS ❑6.STATE AGENCY <br /> 1-13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> M. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414 PHONE <br /> us <br /> Chevron Products Company, Attn:Permit Desk 925-842-9002 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O.Box 6004 <br /> CITY an 1 STATE 41s ZIP CODE 419 <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE E 1.CORPORATION-E]2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT LJ6.STATEAGENCY 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 11 19 1 1 1 3 1 Call(916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) E L SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND - ❑ 10.LOCAL GOVT MECHANISM <br /> [12.GUARANTEE [15.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 notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY [12. PROPERTY OWNER N 3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE424 PHONE 425 <br /> D. R. LERI 4/16/02 925-842-9064 <br /> NAME OF APPLICANT(print) 4M TITLE OF APPLICANT 427 <br /> Chevron Products Company/D.R.LERI Retail ESH Specialist <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Far local use only) 429 <br />