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IAZ, Ct �,�TiG;� A,/1 UNIFIED PROGRAM CONSOLIDATED FORM 9 UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION- FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. (Check one item only) Z 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# 2 (Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. Chevron Station#209167 BUSINESS SITE ADDRESS 103. CITY 104. 1234 Yosemite Ave Manteca, CA 95336 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 ® 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. STATE 418. ZIP CODE 419. San Ramon CA 94583 OWNER TYPE: ® 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- 1013111911131 Call 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: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423. ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. VII.APPLICANT SIGNATURE Y CERTIFICATION: I certify t the information provided herein is true,accurate,and in full compliance with legal r rements. APPLICANT SIGNATURE DATE 424. PHONE "' 425. 06/11/2009 925-842-90co . .; APPLICANT NAME(print) 426_ APPLICANT TITLE -;u+ 427 Chevron Products Compa y/J M HARTMAN Retail HES Permit Desk UPCF UST-A Rev.(12/2007)