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�' PRM:PRo231057 <br /> J1vII+IED PROGRAM CONSOLIDATED FORM iU'`,)v' �'1 FAC 8:FA0003 <br /> 720 <br /> UNDERGROUND STORAGE TANKS-FACILITY 0 uA lip13 v 10 7 <br /> (one Page Per site) <br /> TYPEOFACTION ❑ I NEW SITE PERMIT ❑3.RENEWAL PERMIT �S.CIMNGEOFINFORMATION ❑7 PERMANFNTLYCLOSED SITE <br /> (Chock one iteai«IY) ❑4.AMENDEDPERt awdrydm "memb ❑8.TANK REMOVED <br /> ❑6 TEMPORARY SITE CLOSURE 400 <br /> 1.FACILITY/SITE INFORMATION 508 W CHARTER WAY,MX KMN <br /> BUSINBSSNAME(saacm fACdDYWANBmoAa-DmoaEe�As7 y FACILITY IDM PR IDM 1 <br /> 0 PRO231057 <br /> CHEVRON#92033' FAOo0372 <br /> NEARF41' ONS TREET FACILITY OWNER TYPE 04.LOCAL AGMCY/DISTRICT' <br /> 401 M I.CORPOR,4nGN <br /> CHARTER <br /> BUS ❑s. ourmAGENCY' <br /> INESS INDIVIDUAL '6.STATE AGENCY <br /> I GAS STATION ❑3.FARM ❑5.COMMERCIAL- ❑Z INDIVIDUAL ❑ � <br /> TYPE ❑2.DISTMUTOR ❑4 PROCESSOR ❑6.OT M +m ❑3.PARTNERSHIP ❑1.FEDERALAGPNCY' <br /> TOTAL NMMER OF TANKS ]a facility oo ltd)an R vafion or 'Voanm dllSTmapubl¢aRmt3:rvae dwymrm ddissim2 smtianv�«wkkh apetaces <br /> REMAINING AT SITE truwuws? the USPTlhu is thecarum leen for the tank rcwrda) <br /> 3 ew 0 Yes ®No 4as CHEVRON USA 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4m PHONE 408 <br /> L �)EYTE ErJ 6c FlAQOT ErAL a?O -�/ - 59� <br /> MAILING OR STRE6T ADDRESS <br /> }f2&-&?rUNTRR-ST- s'o6 W LvtJ& v l 6►J Q t/E <br /> CIIIs STATE 4LI ZB CODS �52�? 41: <br /> TY <br /> STOCKTON CA <br /> PROPERTY OWNER TYPE ® I.CORPORATION 02.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> 03.PARTNIIL4BP [15.COUNTY AGENCY [17.FEDERAL AGENCY 413 <br /> IQ.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414PHONE 7, 41s <br /> SA INI SURINDERSINGH <br /> MAILING OR STREET ADDRESS 416 <br /> CITY1565 LAKETREE CT 417 zIP coDE 419 <br /> STATE Ota <br /> SAN JOSE CA 95131 <br /> TANKOWNER TYPE ® 1.CORPORATION 02.INDIVIDUAL 04.LOCAL AGENCY/DISTRICT Cl 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑S.COUNTY AOENCY ❑7,FBDBRAL AGDNCY <br /> IV BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 44-024510 Call(916)372-9669 if questions arise 421 <br /> V PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(8) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ to.LOCAL GOVT MECHANISM <br /> 02.GUARANTEE ❑S.LETTER OF CREDIT ` S.SfATEF'IINDRCPOLM-M M;99.01HER <br /> 113.INSURANCE ❑6.EXEA VnON b-9.STATE FUND R W 4R <br /> IT.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> LMck ons box to iedinm which.ddr^,=eM1aaW be wed f« eod maid", ® 1.FACILITY ❑2.PROPERTY OWNER )]3.TANK OWNER 428 <br /> Legal rotififaliotu end mailM gI be smrwde tmk owum.mlmsbw1«2 o dv2ed. <br /> VII.APPLICANT SIGNATURE <br /> CertiEeation Tee rythatde Wbanpmeidd Lem i.Neandawavo to She beesofm kwe`I d <br /> SIGN OF APPLI T DATE a PHONE 425 <br /> N FAPP CANT(pnnt p6 OFAP CANT 4n <br /> UFZII zH �m; � Gtr <br /> STATE UST FACH,ITY NUIuIDFRIF«ImalwmLy) 428 1998 UPGRADE CERTIFICATE NUMBIIt lfa.�mta mdr) 429 <br /> (s 1998 Compliant?Y <br /> UPCF(1/99 revised) <br />