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UJ/il/2004 08: 35 2094683433 FIFTH FLOOR PAGE 03 <br /> ' „,JNIFIED PROGRAM CONSOLIDATED FORM. - <br /> PR#:PRO231462 <br /> FAC#:FA0003707 <br /> UNDERGROUND STORAGE TANKS -FACILITY <br /> (one page pw Bite) <br /> TYPE OF ACTION ❑ I.NEw$RE PER MIT ❑3,RENEWALPERMIT <br /> (Cheek ooe itrnr only) JCHANGE OFINFORMATION 117.PQLMANENTLV CLOSED$ITE <br /> ❑4.AMENDEDPERMIT /) <br /> ❑ 4.T'ANLREMOVPD <br /> ❑6.TEMPORARY SITE CLOSURE 40r <br /> I•FACILITY SITE INFORMATION <br /> 1�W YOSEMITE AVE MANTECA <br /> BUSINESS NAME(ax�4 FALIlITY ww$nr new-Daq aw�wrAa) s FACII]TY mk <br /> CHEVRON#9-1848 PR 1Die <br /> NEAREST ET PA0003707 PR0231463 [ <br /> YOSEMITE P1 FAC IYUWNERI V,. ❑ALOCALAGEN'CY/D67RIC7• <br /> BUSINESS ❑ I.CORPORATIM ❑ s,coDNTYncENCY• <br /> ❑ 1,GAS STATION ❑3.FARM ❑2.INDMDVAL <br /> TYPE ❑ J.OTIER GLV. ❑6.STATEAOENCY- <br /> ❑2.DISTRIBUTOR ❑1.PROCESSOR ❑ 6.OTF2ER 103 ❑3-PARTNERSII[P 4M <br /> TOTAL NUMBEROFT ❑ 7,FEDERAL AGENCY- <br /> REMAINING AT SITE tostfmds on Indian Reservation or <br /> ttW[lands? •((ownerof. ieapublic a$wcy:nameafwpmimr ofdiKxion,scaion or olEee which op"ame <br /> the UST(This is fie toner[Prison for[he mak records.) <br /> ^° ❑Yes ®No ao3 CIEVRON USA 4" <br /> II,PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAnM£ __ ++ <br /> lJE`j 49I PHONE A479- -��-7�L' 401 <br /> MAILING OR STREET ADDRESS ^ <br /> -FA$6X 61164 �`L 1-e� ��� 409 <br /> CITY <br /> slo $TATE 411 DE' <br /> M�tJ�e� �- CZIP CO <br /> � 2 <br /> PKOPYRTYOWNPR TYPE ® 1.CORFORATION ❑ Z-DVIV1DUAL ❑ 4.LOCAL AGENCY I DISTRICT <br /> L ❑ 6.STATE AGENCY <br /> 03.PARTNERSHIP Cl S.COUNTY AGENCY ❑ 7,FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAA E <br /> MAl}U�NGORr�57AEEr�T AD DRESS age ALLfc ARD PP.scl LL< y <br /> Tai nV1u 0UV4 '0 �OX S2--1 416 <br /> CITY <br /> M <br /> 417 1 STATE alg ZIP CODE alf <br /> TANKOwNER TYPE /'/ `CA' e'er 95'33 <br /> ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑d.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> L L C ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> j W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TQC "'�''' a e � L -1 t all(916)322-9669 ifquestionS Ruse Ql <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) 1 SELF-INSURED ❑4.SURETY BOND 7.STATE PUNA <br /> ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ S.STATE FUND&CFO LETTER ❑99.OTL(ER <br /> ❑3.INSURANCE Cl 6.EXEMPTION ❑ 9.STATE FUND&CD 42y <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chock one bhe a irdicae which addrae should be used br legal narificnions and mrilink. <br /> ® 1.FACIIlIY 02.PROPERTY OWNER Z),TANK OWNER 4n <br /> Legtl nolificadona and mailing wiB he un[b Ne unk owner nnlees box 1 or 2 if chacketl. <br /> VII.APPLICANT SIGNATURE <br /> CaeRati,r, I mvi qal the lalbrmalion pravided hemin is nvS red"curate 10[he heel ofmy knowledge <br /> SIGNATURE OF APPLICANT GATE 420 pH NE <br /> ,,p9 4u <br /> NAME OF APPL[CA T' Print � ' & <br /> -O 1 -,62 3-1 L P <br /> 4m TITLE OF APPI3CANT <br /> U' <br /> 0 r! f4, <br /> STATE UST FACILITY NUMBER(Tmierar,,.dua) 424 L99$UPG)WJE CERTIFICATE NUMBER(Fommwaenlyl 420 <br /> Is 1995 Compliant?Y <br /> UPCF(1/99 revised) <br />