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IFIED PROGRAM CONSOLIDATED FO i <br /> i4. 'rib TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page t of 1 <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT [13.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ ZPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ S.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(S.as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# O O Q 0 0 O O O O O 0 1 <br /> Chevron Station#91848 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT` <br /> 1257 W.Yosemite Ave.,Manteca,CA 95337 ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS M 1.GAS STATION ❑3.FARM LJ 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> 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 <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 3 ❑ Yes ® No 405 406 <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Chevron Products Company, Attn:Permit Desk L2375 B-3 925-842-9002 <br /> MAILING OR STREET ADDRESS 408 <br /> P.O.Box 6004 <br /> CITY 410 1 STATE 611 ZIP CODE 412 <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE O L CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Chevron Products Company, Attn:Permit Desk L2375 B-3 925-842-9002 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O.Box 6004 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL El4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY azo <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 0 1 3 1 1 1 9 1 1 1 3 1 Call 916 322-9669 if questions arise - 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ® 1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND [110.LOCAL GOVT MECHANISM <br /> [-12.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER:_ <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY [12. PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information vided herein is true and actuate to the hest of my knowledge. <br /> SIGNATURE OF T DATE 420 PHONE 425 <br /> tD.R. Leri � 9/3/02 925-842-9064 <br /> NAME OF APPLICANT print 426 TITLE OF APPLICANT p27 <br /> Chevron Products Company/D.R.Leri Retail ESH Specialist <br /> STATE UST FACILITY NUMBER(For loeal u:r only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local we only) 429 <br /> UPCF(1/99 revised) 171 Formerly SWRCB Form A <br />