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Aw, <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <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 ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> 3 (Agency Use Only) C <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Chevron Station# 96171 <br /> BUSINESS SITE ADDRESS 103 CITY 104, <br /> 6633 Pacific Ave Stockton, CA 95207 <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 /> Lincoln Properties LTD (925)842-9002 <br /> MAILING ADDRESS 409. <br /> 374 Lincoln Center <br /> CITY 410. STATE 411. ZIP CODE 411 <br /> Stockton CA 95207 <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 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- 1013111911131 Call 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 OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredfor Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that*e information provided herein is true,accurate,and in full com liance with legal f ments. <br /> APPLICANT SIGNATURE DATE 424, PHONE 425. <br /> 06/10/2009 925-842-90 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE c 427 <br /> Chevron Products Compan JI ARTMAN Retail HES Permit Desk <br /> Y <br /> e <br /> UPCF UST-A Rev.(12/2007) <br />