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LIRMD PROGRAM CONSOLIDATED FO <br /> PRESIJBiVII'ITAL TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page 1 of 1 <br /> TYPE OF ACTION ® I.NEW SITE PERMIT [13.RENEWAL PERMIT 0 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 4pa <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(sememFACUMNAMEorDBA-Doing Business As) 3 FACILITY ID# <br /> Chevron Station#210997 0 0 0 0 0 0 00 0 0 0 1 <br /> NEAREST CROSS STREET 403 FACILITY OWNER TYPE 4.LOCAL GENCY/DISTRICT- <br /> Hwy 99&Colony Drive,Ripon CA 95366 ® 1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS 1.GAS STATION 0 3.FARM 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY" 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •If owner ofUST 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 407 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 1 STATE 411 <br /> ZIP CODE 412 <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE O L CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNERNAME 414 PHONE <br /> 415 <br /> Chevron Products Company, Attn:Permit Desk 925-842-9002 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O.Box 6004 <br /> CITY 417 STATE 419 ZIP CODE 419 <br /> San Ramon CA 1 94583 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT LJ6.STATBAGENCY 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 3 1 1 1 9 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 ❑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 notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. 0 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is one and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> D. R. LERI 4/16/02 925-842-9064 <br /> NAME OF APPLICANT(print) 426 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(For local use only) 429 <br />