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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <�JAJ <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404, FACILITY ID# <br /> 3 (Agency Use Only) S <br /> BUSINESS NAME(Same as Facilily Name or DBA-Doing Business As) 3. <br /> Chevron Station# 201383 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1960 W 1 lth St. Tracy, CA 95376 <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Chevron Products Company, Attn:HES Permit Desk L2375 (925)842-9002 <br /> MAILING ADDRESS 409. <br /> P.O. Box 6004 <br /> CITY 410TCA <br /> STATE 411. ZIP CODE 412. <br /> San Ramon 94583 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 428-2. <br /> Chevron Products Company, Attn:HES Permit Desk L2375 (925)842-9002 <br /> MAILING ADDRESS 428-3. <br /> P.O.Box 6004 <br /> CITY 428-4. STATE 428-5, ZIP CODE 428-6. <br /> San Ramon I CA 94583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Chevron Products Company, Attn:HES Permit Desk L2375 (925)842-9002 <br /> MAILING ADDRESS 416, <br /> P.O. Box 6004 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> San Ramon CA 94583 <br /> OWNER TYPE: ® 1.CORPORATION ❑ 2.COUNTY AGENCY ❑ 3.STATE AGENCY 420. <br /> ❑ 4.FEDERAL AGENCY ❑ 5.NON-GOVERNMENT ❑ 6.LOCAL AGENCY/DISTRICT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10311911131Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423. <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERQR. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> } <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I ceriftv that the information provided herein is true,accurate,and in full com liance with legal require`enfs. <br /> APPLICANT SIGNAT DATE 424 PHONE 425, <br /> Tli� 06/08/09 925-842-9002 <br /> P <br /> APPLICANT NAME(print) I 426. APPLICANT TITLE 427 <br /> Chevron Products Co p ny/Jim Hartman Retail HES Permit Desk <br /> UPCF UST-A Rev.(12/2007) <br />