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Is ops' <br /> IFIED PROGRAM CONSOLIDATED FO <br /> � [ � TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page I of 1 <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check oneitemonly) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same.FACILITY NAME or DBA-thing Business As) 3 1 FACILITY IDk O O O 0 U O O O O O 0 <br /> Chevron Station#98264 7 r <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> 3775 Trac Blvd.,Trac ,CA 95376 ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION ❑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 of UST 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 /> 3 ❑ Yes ® No 405 4oe <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> KEIL SONOMA CORP 925-842-9002 <br /> MAILING OR STREET ADDRESS ao5 <br /> 244 KEARNY ST <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> SAN FRANCISCO CA 94108 <br /> PROPERTY OWNER TYPE Lj 1.CORPORATION 0 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY 413 '. <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414 PHONE 415 <br /> Chevron Products Company, Attn:Permit Desk L2375 B-3 925-842-9002 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O.Box 6004 <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE 1.CORPORATION Lj 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> [13.PARTNERSHIP [15.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 1 9 1 1 1 3 1 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ® 1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER:_ <br /> ❑3.INSURANCE [16.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 1 or 2 is checked ❑ 1.FACILITY [12. PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify the in d #o m d herein is true and accmr w the best of my krwwledge. <br /> SIGNATURE P DATE 424 PHONE 425 <br /> (D.R. Le 8/30/02 925-842-9064 <br /> NAME OF APPLICA print) 426 TITLE OF APPLICANT d27 <br /> Chevron Products Company/D.R.Leri Retail ESH Specialist <br /> STATE UST FACILITY NUMBER(For bw ase only) 428 1998 UPGRADE CERTIFICATE NUMBER(For IoW ase only) 429 <br /> UPCF(1/99 revised) 171 Formerly SWRCB Form A <br />