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UNIFIED PROGRAM CONSOLIDATED FORM HECEIVED <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFO <br /> RMAMONo9 r C <br /> (One form per facility) <br /> ,Q 1. UU11y Illy <br /> TYPE OF ACTION ❑ 1.NEW PERMIT [:15.CHANGE OF INFORMATION ❑ 7.PER aoo. <br /> (Check one item only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE El 9.TRANSFER P SERVICES <br /> s. <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# _ _ L <br /> 3 (Agency Use Only) 164 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) F Q 3. <br /> Chevron Station# 96171 Nt�ti4p M�cOUN <br /> BUSINESS SITE ADDRESS 103. CITYi ART 104. <br /> 6633 Pacific Ave Stockton, CA 952N <br /> Mr <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 412. <br /> Stockton CA 95207 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428`1. PHONE 428-2. <br /> Chevron Products Company, AUn: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 ata. 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 ago. <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(Required for Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 PHONE 425. <br /> TREO W,4R INEZ 01/12/2009 925-842-9002 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Chevron Products Company/FRED MARTINEZ Retail HES Permit Desk <br /> UPCF UST-A Rev.(12/2007) <br />