BILLING_2009 - 2015 - Laserfiche WebLink

Home Browse Search

UNIFIED PROGRAM CONSOLIDATED FORM/7 UNDERGROUND STORAGE TANK % e -e-, OPERATING PERMIT APPLICATION - FACILITY INFORMATION (One form per facility) bfQ O TYPE OF ACTION ® I. NEW PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 400. (Check one item only) ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ® 9. TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 4°4. FACILITY ID #_ _ / LzL 3 (Agency Use Only) BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) 3. Chevron Station# 307709 BUSINESS SITE ADDRESS 103. CITY 104, 10858 Trinity Parkway Stockton, CA 95219 FACILITY TYPE Z 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 Z 2. No II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. Levine Investments LP (925) 842-9002 MAILING ADDRESS 409. 1661 E. Camelback Road, Ste 375 CITY 410. STATE 411. ZIP CODE 412. Phoenix AZ 85016 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 428-3. 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 1 CA 94583 OWNER TYPE: Z 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- 0 3 1 9 1 3 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 Z 3. TANK OWNER ❑ 5. FACILITY OPERATOR SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required for Public Agencies Only) 406 VII. APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true, accurate, and in full com liance with legal re uiremen s . APPLICANT SIGNATURE DATE 424. PHONE 425 ilk" 08/13/09 925-842-9002 APPLICANT NAME (print) 426. APPLICANT TITLE 427 Chevron Products Company/ JIM HARTMAN Retail HES Permit Desk UPCF UST -A Rev. (12/2007)