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.acali$yj$i$e <br /> CHEVRON STATION#99840* CERS ID <br /> 4344 E WATERLOO RD 10181341 <br /> STOCKTON,CA 95205 <br /> submittal Status <br /> Submitted on 1/16/2014 by Ron Stevens of Chevron Products Company(A Division of Chevron U.S.A.Inc.)(San Ramon) <br /> Comments by submitter:This is the initial CERS UST Information submittal.If you have any questions or if further action is necessary,please contact Charles Bittle at <br /> cbittle@chevron.com or call 925-842-9002. <br /> '�' flf Aclort <br /> :Renewal Permit <br /> �aCillty infara$ion ' Tank Operator <br /> CHEVRON STATION tt99840* [CHEVRON PRODUCTS COMPANY(A DIVISION OF CHEVRON U.S.A.INC.) <br /> 4344 E WATERLOO RD Ii925)842-9002 <br /> STOCKTON,CA 95205 1P.O.BOX 6004,ATTN:PERMIT DESK <br /> J acility Type Board of Equalization Account Number SAN RAMON,CA 94583 <br /> Motor Vehicle Fueling 44031913 <br /> #s the fac€€ity located on Indian Reservation/Trust lands? <br /> !lo <br /> raperty£IWner ank".ner <br /> JOSEPH A BUDISELICH TRUSTEE OF ANTOINETTE BUDISELICH TRUST CHEVRON PRODUCTS COMPANY(A DIVISION OF CHEVRON U.S.A.INC.) <br /> .k209)210-7443 925)842-9002 <br /> 1159 WESTBRIDGE DR P.O.BOX 6004,ATTN:PERMIT DESK <br /> IODI,CA 95242 SAN RAMON,CA 94583 <br /> Tank Owner Type <br /> on-Government <br /> �&rntt bolder lnforrnidOn <br /> Pere-nit Holder Notification Information Supervisor of Division,Section,or Office(Required for Public Agencies Only) <br /> facility Owner <br /> financial espwsi ility Mechanisms) <br /> Jndlcate which approved mechanism(s)are being used to show financial responsibility either as contained in the federal regulations(40 CFR,Part 280,;subpart H,Sections 280.93 through <br /> X80.107)or CCR,Title 23,Division 3,Chapter 38.Section 2808.1. <br /> Self-Insured Surety Bond State Fund and CFO Letter Other mechanism <br /> :Yes <br /> guarantee Letter of Credit :state Fund and CD <br /> i€nsurance Exemption Local Government Mechanism <br /> Applicant Certification <br /> Itapplicant Name Applicant Title Applicant Phone Date Certified <br /> PON STEVENS . RETAIL OE/HES SPECIALIST (925)842-9002 1/16/2014 <br /> a� <br /> Printed on 1/20/2014 11:07 AM <br />