COMPLIANCE INFO_1999-2007 - Laserfiche WebLink

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FIED PR CONSOLIDATED FO - TANKS UNDEIROST RAG9-,- KS '- AGILITY (one page per site) Page I of I TYPE OF ACTION ❑ 1.NEW SITE PERMIT a 3.RENEWAL PERMIT 0-5,CHANGE OF INFORMATIONQ 7.PERMANE.NTLY CLOSED SITE (Check one item only) Q 4.AMENDED PERMIT specfy change local use only . ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 406 t I. FACILITY/ SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) s FACILITY ID# 0 0 0 0 0 0 � 0 0 0 0I0 Chevron Station#208118 1;; NEAREST CROSS STREET 401 FACILITY OWNER TYPE 4.LOCAL GENCY/DISTRICT Holman ® 1.CORPORATION ❑5.COUNTY AGENCY- BUSINESS 1.GAS STATION 3.FARM 0 5. COMMERCIAL ❑ 2.INDIVIDUAL p 6.STA-1 E AGENCY" TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY- 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •If owner of t)ST is a public agency:name o supervisor of division,section or oSice which REMAINING AT SITE trustlands? operates the US"r(This is the contact person for the tank records.) 2 404 ❑ Yes ® No 405 _ 406_ II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 Chevron Products Company 925-842-99002 v MAILNG OR STREET ADDRESS 409 I P.O.Box 6004 _ CITY Oto ST- ATE - 411 ZIP CODE 4:z San Ramon CA 94583 PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL OTL6CAL AGENCY/DISTRICT ❑6.STATE AGENCr' _ ®3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 I III. TANNK OWNER INFORMATION TANK OWNER NAME 41__1 PH( F 4ts Chevron Products Company 925-842.9002 MAILING OR STREEADDRESS 4Ia STREETADDRESS P.O. Box 6004 CITY 417 STATE 4)9 ZIP CC)DE 419 San Ramon CA9� 458"s TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT LJ 6.STATE AGENCY 420 ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 0 3 I 9 Call(916)322-9669 if questions arise 421 V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ®1 SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: ❑3.INSURANCE ❑6.EXEMPTION ®9.STATE FUND&CD 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. 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 VII. APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGA L�CANT T DATE � 424 PHONE 42s 1 9!20/99 925-842-9002 NAME APPLICANT(print) 426 TITLE OF APPLICANT 4z7 D.R. LERI Retail ESH Specialist STATE UST FACILITY NUMBER(For local.only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 UPCF(1/99 revised) 171 Formerly SWRCB Forms A