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RECEIVEDk((bI tti UNIFIED PROGRAM CONSOLIDATED FORM FEB 13 2009 !�i' lB I UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION- FACILITY IWIMYSERVICES OUNnr (One form per facility) TYPE OF ACTION El 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT F C LSfJRE ft400. 400. (Check one item only) Z 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT tr I. FACILITY INFORMATION B 2 TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID / 1/'J t 2 (Agency Use Only) e?:d1f 42 BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 4� Chevron Station# 201761 BUSINESS SITE ADDRESS 103, CITY 104. 1103 S. Main St. Manteca, CA 95337 FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes Z 2.No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407, PHONE 408, Chevron Products Company, Attn:HES Permit Desk L2375 (925)842-9002 MAILING ADDRESS 409. P.O. Box 6004 CITY 410. STATE 411. ZIP CODE 412. San Ramon CA 94583 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. PHONE 428-2. Chevron Products Company, Attn:HES Permit Desk L2375 (925)842-9002 MAILING ADDRESS 428.1 P.O. Box 6004 CITY 4284. STATE 428-5. ZIP CODE 428-6. San Ramon CA 94583 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. Chevron Products Company, Attn:HES Permit Desk L2375 (925)842-9002 MAILING ADDRESS 416. P.O. Box 6004 CITY 417. 1 STATE 418. ZIP CODE 419. San Ramon CA 94583 OWNER TYPE: Z 1.CORPORATION ❑'2.COUNTY AGENCY ❑ 3.STATE AGENCY 420. ❑ 4.FEDERAL AGENCY ❑ 5.NON-GOVERNMENT ❑ 6.LOCAL AGENCY/DISTRICT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 01311911131Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI. PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: El1.FACILITY OWNER ❑ 4.TANK OPERATOR 423. Z 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 424, PHONE 425_ T E(D XAR INEZ 01/13/2009 925-842-9002 APPLICANT NAME(print) 426. APPLICANT TITLE 427 Chevron Products Company/FRED MARTINEZ Retail HES Permit Desk UPCF UST-A Rev.(12/2007)