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• FIED PROGRAM CONSOLIDATED FORM* 11026 ..5 ,n P 110231665 A� 't�lef_ F., �#: 0003714 UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOS SIE"') (Check one item only) El 4,AMENDED PERMIT El 8,TANK REMOVED Iy, ❑6.TEMPORARY SITE CLOSURE IV00 I.FACILITY/SITE INFORMATION 334 E MAIN ST,RIPON BUSINESS NAME(Sw NFACRIT NAM wDBA-Doing Bmlmss As) 3 FACILITY ID' PR ID# LACHHAR CHEVRON* FA0003714 PR0231665 FT I NEAREST CROSS STREET FACILITY OWNER TYPE 401 ❑ 4.LOCAL AGENCYNISTRICT' [T 1.CORPORATION ❑ 5.COUNTY AGENCY' BUSINESS ❑ 1.GAS STATION ❑ 3.FARM C15.COMMERCIAL E] 2.INDIVIDUAL El 6.STATE AGENCY' ,TYPE El2.DISTRIBUTOR [14.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or •If owner of UST is a public agency:name of supervisor of division section or office which operates REMAINING AT SITE trustlands? the UST(Thu is the contact person for the tank records.) 404 ❑ Yes M No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME w7 PHONE 408 GWENDOLYN SCHEFFER TRUST MAILING OR STREET ADDRESS d09 PO BOX 63408 CITY 410 STATE 411 ZIP CODE 412 SAN FRANCISCO I CA 94163 PROPERTY OWNERI'YPE ® I.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY DISTRICT 06.STATE AGENCY E13.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 CHEVRON USA 925 842-9002 MAILING OR STREET ADDRESS 416 PO BOX 6004 CITY 417 STATE V18 ZIPCODE a19 SAN RAMON I CA 94583 TANK OWNER TYPE 191 L CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ago ❑ 3.PARTNERSHIP 1:15.COUNTY AGENCY . ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-031913 1 Call(916)322-9669 if questions arise 021 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) X❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHAMSM ❑2.GUARANTEE ❑ S.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 1:199.OTHER 1:13.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 meding. ❑ 1,FACILITY ®2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I cMify,that the information provided herein is true and accurate to the best ofmy knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 475 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For leM=My) 429 1998 UPGRADE CERTIFICATE NUMBER(Fer lase)meanly) 429 Is 1998 Compliant?Y UPCF(1/99 revised)