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v NIFIED PROGRAM CONSOLIDATED FOR1PR#:PRM1463 � FAC#:FAOOM707 UNDERGROUND STORAGE TANKS -FACILITY (one page per site) TYPE OF ACTION ❑ L NEW SITE PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION (Check one item only) ❑ 7.PERMANENTLY CLOSED SITE E]4.AMENDED PERMIT /( ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 1257 W YOSEMITE AVE.MANTECA BUSINESS NAME(tint.FACILITY NAME-DBA-Doing makers At) FACILITY ID# PR ID# CHEVRON#9-1848 FA0003707 PR0231463 NEAREST CROSS STREET FACILITY OWNER TYPE YOSEMITE °01 ❑ 1.CORPORATION ❑4.LOCAL AGENCY/DISTRICT- YOSEMITE GE AGENCY- BUSINESS NCY-STRICT• BUSINESS ❑ S.STATECOLJNAGENCY- TYPE ❑ 1.GAS STATION ❑ J.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY• ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ T,FEDERAL AGENCY' 403 TOTAL NUMBER OF TANKSLs facility on Indian Reservation or 'Ifowner of UST is a ublic a rn REMAINING AT SITE trustlands? P B cy:name of supervisor ofdivision,section or office which operates the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 905 CHEVRON USA 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 40'1 PHONE 'tall GOR STREET ADDRESS CITY 010 STATE 0-c-I.\- L'7� zIP coD _ -3= PROPERTY OWNER TYPE I.CORPORATION ❑ 2.INDIVIDUAL 114.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANKOWNERNAME ata PHONE 415 MAR24G OR STREET ADDRESS 416 - p CITY 417 STATE 418 ZEPCODE 419 --3fcP'RAf9f0N S -94n TANK OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-031913 1 Call(916)322-9669 if questions arise 031 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) [XI 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 1:199.OTHER ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® 1,FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that Ne information provided herein is true and accurate to the best ofmy knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For mot mads) 429 1998 UPGRADE CERTIFICATE NUMBER(Forlow use any) 429 Is 1998 Compliant?Y UPCF(1/99 revised)