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UNIFIED PROGRAM CONSOLIDATED FORM $ f!9 Q 9 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ t NEW PERMIT ❑ 5.CHANGE OF INFORMATION <br /> (Check one item only) ❑ Z PERMANENT FACILITY CLOSURE 4W <br /> ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF'USTs AT FACILITY 4M FACILITY ID# _ _ 1. <br /> 3 (Agency Use Only) l <br /> BUSINESS NAME(Some as Facility Name or DBA-Doing Business As) 3, <br /> Chevron Station# 98264 <br /> BUSINESS SITE ADDRESS 103, CITY 104 <br /> 3775 Tracy Blvd Tracy, CA 95304 <br /> FACILITY TYPE ® L 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 /> Chevron Products Company, Attn:HES Permit Desk L2375 (925)842-9002 <br /> MAILING ADDRESS 409. <br /> P.O.Box 6004 <br /> CITY 410- STATE 411. ZIP CODE 412. <br /> San Ramon CA 94583 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4ze-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 428fi <br /> San Ramon CA 94583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 474. PHONE 415. <br /> Chevron Products Company, Atm: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- 3 1 9 1 3 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 4D <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required far Puhfic 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 re uire <br /> APPLICANT SIGNATURE DATE 424. PHONE _ 425. <br /> tFP9(DWAR97ATEZ 01/14/2009 925-842-9002 <br /> APPLICANT NAME(print) 426- APPLICANT TITLE P.":.1 427 <br /> Chevron Products Company/FRED MARTINEZ Retail HES Permit Desk C.2 <br /> UPCF UST-A Rev.(12/2007) <br />