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/ - TTFIED PROGRAM CONSOLIDATED FC 4 px�- Cj\ <br /> `.", Bmf Ao1$\o"Y TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page 1 of I <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 4°n <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# O O O O O O O O Q Q 1 <br /> Chevron Station#91848 Oqp <br /> NEAREST CROSS STREET I01 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT- <br /> 1257 W.Yosemite Ave.,Manteca CA 95336 ® 1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS 0 1.GAS STATION Lj 3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR[16. OTHER 03 ❑ 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 tmatlands? operates the UST(This is the contact person for the tank records.) <br /> 3 ❑ Yes ® No 405 ea6 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME eon PHONE 408 <br /> Chevron Products Company, Attn:Permit Desk L2375 B-3 925-842-9002 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O.Box 6004 <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> San Ramon CA 94583 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> IH.TANK OWNER INFORMATION <br /> TANKOWNERNAME 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 1 STATE 418 ZIP CODE 419 <br /> San Ramon CA 94583 <br /> TANK OWNER TYPE L9 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑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 13 1 1 19 1 1 13 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 ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER:_ <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FIND&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 03.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> G R Canfw[d 06/27/2002 925-842-9002 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 422 <br /> Chevron Products Company/C.R.Canfield Retail ESH Specialist <br /> STATE UST FACILITY NUMBER(For local me only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 171 Formerly SWRCB Form A <br />