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UJ/11/20U4 08:35 2094683433 FIFTH FLOOR <br /> PAGE 03 <br /> i.IFIED r,GcC IL'tM CONSOLIDATED FORM 'reew <br /> PR N:PR0231463 <br /> FAC N:FA000m <br /> UNDERGROUND STORAGE TANKS -FACILITY vyn <br /> (one page per site) k' �� <br /> TYPBOPACTION ❑ I.NEWSITEPERMIT 03.RL PEIIENEWA <br /> (Ch<ck one itun Doty) <br /> 4.AMENDED PERMI7 5.CHANGEOFINFORMATION 7.PERMANFNTLYCLOSED SITE <br /> Q <br /> ❑ d.TANk RLMOVPD <br /> ' ❑6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION 1� 4Qd <br /> 7w YOSEMITE AVE MANTECA <br /> 13USWESS NAME(s.n ypAm,OY Nyrg doe A.DNnhawi.e,A,) 3 FACIllTY m% PR 1Dl1 <br /> CHEVRON#�-1848 FA0003707 <br /> NEAREST CROSS STREET PRO231463 <br /> YOSEMITE wI FACILITY OWNER TYPE <br /> ❑ LCORPOMTim ❑a.LOCAL AGENCYIDt5TRICT' <br /> ❑ I.GAS STATION 3.FARM ❑ 2.NOMOVAL ❑ 5.COUNTY AGENCY' <br /> TYPE ❑ ❑ f.COMMERCUL ❑ 6,STATE AOLNCY' <br /> ❑ 2.DISTIURUTOR ❑ 4.PROCMSOR ❑ 6.GTNER 101 ❑3.pARTNmsIiR <br /> TOTAL,NUMBER OFT Cl T,FEDERAL AGENCY- 461 <br /> REMAINING AT SITE <br /> Ia}Scanty on Indian Reservation or •Ifowner ofVSiies publi Seery:mme afsupervisor efdiHsism,section or ofieewhieb opus. <br /> tnpstlpndl? We UST(This is we convetoersOn for rhe uek reeor"0 <br /> a <br /> loyea ® No 461 CHEVRON USA <br /> 4os <br /> IJ.PROPERTY OWNER INFORMATION <br /> YRUPER••7Y,,O OWNER NAME <br /> IV J A �4IJ /'O L� aor PHONE ,.,,p' <br /> a"/ ZtS-/�_ / <br /> MAILING OR STREET ADDRESS lop <br /> ❑TYF�9 2 'l �N . `(o S�J�1 i I e gv eJ 40 <br /> Ma'N ec.� u0 STATE ZIPCODE <br /> .rd <br /> v^f <br /> YROPERTYOWNER TYPE <br /> ® I.CORPORATION ❑ 2.INDIVIDVAL ❑ 4.LOCAL AGENCY f DISTRICT <br /> ❑3.PARTNERSHIP ❑ 6.STATE AGENCY <br /> L L ❑1.COUNTY AGENCY ❑ 7.FEDERAL AGENCY au <br /> III.TANK OWNER INFORMATION <br /> rnrlx owNeR NAME <br /> S'4'ej rJ gLLJc .I6 PHoxE7o9- g23-/itzy 41s <br /> MNIJNG OR STREET ADDRESS ROPFJG LII <br /> CITY • ��� S�-L'/ 416 <br /> -8 417 STATE aIA ZIP CODE <br /> r�r e.a 9sa3(o .rr <br /> TANK OWNER TYPE "-CORPORATION ❑ 2.INDIVIDUAL ❑d.LOCAL AGENCY/DISTRICT ❑ G.STATE AGENCY 420 <br /> �-L C ❑3.PARTNERSHIP ❑ 5.COUNT AGENCY ❑ 7.FL•DERAL AGENCY <br /> / / FI'.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Ib d-0'9 2 -)-71all(916)322-9669 if questions arise uI <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(5) 0 1,SELF-INSURED <br /> ❑d.SURETY FOND CK 7.STATE PUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ S.STATE FUND&CFO LETTER ❑99.OTIIER <br /> ❑3.INSURANCE ❑ 6.EXEMPTION Cl 9.STATE FUND&CD <br /> 4D <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Chock new boa a iedicat which Iddras should be used 6r legal noeficuians and moiling. � <br /> Legal norificsbom mailing will ll be ssntowner nnlese bex 1 <br /> mYmunk o12i4 chectetl. QJIM 1.FACILITY ❑2.PROPERTY OWNER 3.7ANKOWNER m <br /> VII.APPLICANT SIGNATURE <br /> Ce,tifiation.l eerYTy dlx rhe 1p6tmstien peNded Bertin is hu ondueur110101hebatoFmy knowledge. <br /> SIGNATUREOF APPUCANT <br /> DATE 4ir PHONE <br /> NAMEOFAPPLICANT' onnl I �� ZDI�OZJ^l L 4ss <br /> /� Np TITLE OFAPPLICAN]' <br /> O iJ (/stLl2 0/ 1 u- •D <br /> STATE UST FAIJT <br /> CIY NUMEER(sw iew�e.N) <br /> 199' UPGRADE T1 NUMBER(s'o IOtlI wemN1 420 <br /> e <br /> Is 19Yb COmpliant7 Y <br /> UPCF(1/99 revised) <br />