Laserfiche WebLink
100.1 <br /> IFIED PROGRAM CONSOLIDATED FqV 17/7/a <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY 0 <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) [14.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 496 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sameas FACILITYNAMEor DBA-Doing Business As) 3 FACILITYID# O O �. O O 0 O 0 0 0 0 O <br /> Chevron Station#91452 ,371 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> 334 E Main St.,Ri on,CA 95366 ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® I.GAS STATION ❑3.FARM -15. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 9f 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 /> 4 ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 46] PHONE 468 <br /> JOSEPH W.IRVINE EXEC OF EST OF G. SCHEFFER 925-842-9002 <br /> MAILING OR STREET ADDRESS 409 <br /> P O BOX 63408 <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> SAN FRANCISCO CA 94163 <br /> PROPERTY OWNER TYPE N 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> [13.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 ® L CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 430 <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 0 3 1 9 1 1 1 3 Cal] 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ® 1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> [:12.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER:_ <br /> ❑3.INSURANCE ❑6.EXEMPTION [19.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 433 <br /> VH.APPLICANT SIGNATURE <br /> Certification-I certify,that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF I TDATE 024 PHONE 425 <br /> QR Geri 9/4/02 925-842-9064 <br /> NAME OF APPLICAN nt) 026 TITLE OF APPLICANT 427 <br /> Chevron Products Company .R.Leri Retail ESH Specialist <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 171 Formerly SWRCB Form A <br />