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MFIED PROGRAM CONSOLIDATED FORM PR#:PR0231057 FAC#:FA0003720 UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT7y�g1{5.CHANGE OF INFORMATION 7.PERMANENTLY CLOSED SITE (Checkoneitemonly) ❑ 4.AMENDED PERMIT / "ikrf' charglred use onh"= ❑ 8.TANK REMOVED ❑b TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 508 W CHARTER WAY,STOCKTON BUSINESS NAME(Semens FACILITY NAME ar DBA-Doing Business As) 3 FACILITY ID# PRID# CHEVRON#92033* FA0003720 PRO231057 NEAREST CROSS STREET FACILITY OWNER TYPE CHAR'I'ER 401 ® I.CORPORATION E]4.LOCAL Y AGENCY- BUSINESS El INDIVIDUAL ❑ .COUNTY - ,TYPE El 1.GAS STATION ❑3.FARM ❑ 5.COMMERCIAL El6b.STATE AGENCY- TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑3.PARTNERSHIP ❑ 7.FEDERAL AGENCY- 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation W *If owner of UST is a public agency:name ofsupmisor of division,section or office which operates REMAINING AT SITE t ustlands? the UST(This is the contact Person for the lank records) 404 ❑ Yes ® No 405 CHEVRON USA 06 IL PROPERTY OWNER INFORMATION PROPERTY OWNER NAME c Tr E 6L NA RUT F_r4 L 407 PHONE Li G C 40g MAILING OR STREET ADDRESS 1rye-s ron SD6 W• LV0Gv 4111EA114� 6 CITY 410 STATE 011 ZIP CODE 412 STOCKTON CA "2oa GI Std-7 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 4s SAINI SURINDER SINGH MAILING OR STREET ADDRESS 416 1565 LAKETREE CT CITY 417 STATE 418 ZIP CODE 419 SAN JOSE CA 95131 TANK OWNER TYPE ❑X I.CORPORATION ❑ 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024510 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ I.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER M 99.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® 1 FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2'.checked. VII.APPLICANT SIGNATURE Certification-I cenify that the inflammation provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 428 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(Fm lrcal seamy) 428 1998 UPGRADE CERTIFICATE NUMBER d cr mem useanlr) 429 Is 1998 Compliant?Y UPCF(1/99 revised)