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55RFIED PROGRAM CONSOLIDATED Folp <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - " TY fl �� � <br /> T /q/�L one a e <br /> ( p g per site) Page I of I <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT 19 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 /> ❑6XEMPORARY SITE CLOSURE 400 <br /> I. FACILITY /SITE INF ATION <br /> pm <br /> BUSINESS NAME(same u AME o <br /> FACILITY Nr DBA-Doing auxinas As) 3 TY FACILIIDN <br /> Chevron Station#200764 0 0 0 0 0 0 0 0 0 0 0 1 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE Ll 4.LOCAL GENCY/DISTRICT* <br /> 4747 West Lane, Stockton CA 95210 ® 1.CORPORATION [15.COUNTY AGENCY- <br /> BUSINESS M 1.GAS STATION 3.FARM 5. COMMERCIAL 2.INDIVIDUAL [16.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP > <br /> ❑7.FEDERAL AGENCY 402 <br /> TOTAL NUMBER OF TANKS IS facility on Indian Reservation or elf owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trusllands? operates the UST(This is the contact person for the tank records.) <br /> 3 ❑ Yes ® No i 405 it 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Chevron Products Company, Attn:Permit Desk L2375 B-3 925-842-9002 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O.Box 6004 <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE 0 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 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 ua 1 ZIP CODE 019 <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE 1XORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)H 44- 0 13 1 1 19 1 1 13 1 Call 916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) N 1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> [12.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. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®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/ DATE 424 PHONE 425 <br /> QR LrERI5/30/02 925-842-9064 <br /> PL <br /> NAME OF APIC (print) 426 TITLE OF APPLICANT 427 <br /> Chevron Products Company/D.R. LERI Retail ESH Specialist <br /> STATE UST FACILITY NUMBER(For kcal use Daly) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use Daly) 429 <br /> I)PCF(1/99 revised) 171 FDrrnrrly C w R C P c- A <br />