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r��► �L9 <br /> LNIFIED 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 <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> 2 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Chevron Station# 208117 <br /> BUSINESS SITE ADDRESS 103, CITY 104. <br /> 755 S. Tracy Blvd Tracy , CA 95376 <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 /> Pepper Lane Monterey Road LLC, CIO Borelli Investment Co. 408-453-4700 <br /> MAILING ADDRESS 409, <br /> 1770 Technology Dr. <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> San Jose CA 95110 <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- 101311911131Call 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 /> Z 3.TANK OWNER ❑ 5.FACILITY OPE <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) t`> "i 406. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certif the information provided herein is true,accurate,and in full compliance with legal re uireme <br /> APPLICANT SIGNATURE DATE 424. PHONE <br /> 06/12/2009 925-842-9002 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Chevron Products Company <br /> J HARTMAN Chevron Retail HES Permit Desk <br /> UPCF UST-A Rev.(12/2007) <br />