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03/17/2004 10:23 2099310-5.50 CHEVRON 1580 v PAGE 01/05 <br />UNDERGROUND STORAGE TANKS - FACILITY <br />I (one page per site) FELSC I Of I <br />TYPE OF ACTION Lj 177 SITE PERMIT CHANGE OF INFORMATION El 7.PERMANENTLY CLOSED $ITF <br />(Check one item only) 0 4. AM;, -Wk r) PERMIT specify change local use only ____ El 8. TANK REMOVED <br />0 6,'TEMPORARY SITE CLOSURE 400 <br />1, FACILITY / SITE INFORMATION <br />BUSINESS NAME (Sarno m FACILITY NAML c, DISH - Doir5wiOu9 As) ? FACILITY <br />0 0 0 Q 0 0 <br />1 L <br />Chevron Station #99840 -L-0 <br />NEAREST CP OSS STR FET 4011 FACILITY OWNER TYPF El 4. LOCAL 0CNCY/]DISTRICT* <br />4344 Waterloo Rd., Stockton, CA 95215 -0 1. CORPORATION El 1. COUNTY AGENCY*BUS <br />ESS 0 1. GAS STATIO=N3. FARM r-1 5. COMMERCIAL El 2. INDIVIDUAL Ej 6. STATE AGENCY* <br />TYPE D 2. DISTRIBUTOR [14. PROCESSOR E3 6. OTHER 4o3 D 3. PARTNERSHIP El 7. FEDERAL AGENCY* 402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />'If owner of VST in u public agency: oalne Qf,%kzPcTvis0r of division, Ycclioft or office which <br />REMAINING AT SITE <br />trustlands? <br />operates the 7JST (This is the contact person for the tank records.) <br />2 <br />El yes 0 No 405 <br />406 <br />11. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 408 <br />Chevron Products Company, Attn: Permit Desk L2375 6-3 <br />925-842-9002 <br />MAILING OR STREET ADDRF.S.S 409 <br />P,O, Box 6004 <br />CITY 410 <br />STATE 411 <br />ZIP CODE 412 <br />San Ramon <br />CA <br />-LOCAL <br />94583 <br />PROPERTY OWNER TYPE 0 1 C ORPORAfJ N [12ANDIVIDUAL 4. ET AGENCY/ DISTRICT EJ6.STATEAGENCY <br />0 1. PARTNERSHIP El 5. COUNTY AGENCY E] 7. FEDERAL AGENCY ata <br />IIS. TANK OWNER INFORMATION <br />TANK -OWN ER NAME did <br />P1IONE 415 <br />Chevron Products <br />847-9002 <br />MAILING OR STREET ADDRESS 4;5 <br />P.O. Box 6004 <br />CITY 417 STATF Sts ZIP CODE 419 <br />San Ramon - CA 94583 <br />TANK OWNER TYPE I. CORPORATION E]2.INDIV(DUAL -- 0 4. LOCAL AGENCY /DISTRICT U6.STATE AGENCY 420 <br />D3.PARTNERSHIP 0 5. COUNTY AGENCY D 7. FEDERAL AGCNCY <br />TV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />4i T 1 19 1 LLLL- Call (916) 322-9669 if questions arise 47.1 <br />J- 3 <br />-iy-(TKHQ <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) 211 - ';FI F-INSI JP ED El 4. SUM. TY BOND ❑ 7. STATE FUND D 10. LOCAL GOVT MECRANISM <br />0 2. GUARANTEE ❑ -5 , LETTER OF CREDI,r ❑ 8. STATE FUND &- CFO LETTER ❑ 99, OTHER: -- <br />0 3. INSURANCE ❑ 6. FXMPTION ❑ 9, S I I E FUND Sc C9 azz <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check ooe box to indicate which address should be used for legal notifications and mailing, <br />Legal notifications and mailings will be sent to the mok owner unless box I or 2 is checked. 0 1. FACILITY El 2. PROPERTY OWNER 0 3. TANK OWNER 423 <br />V11. APPLICANT SIGNATURE <br />Certification - I certify that the informed Aieidek) herein i,, true 3sid,,--wote to the best of nay knowledge. <br />'E <br />SIGNATURE -&VAP-A <br />DATE 474 <br />PIIONF 47A <br />'D R. Let <br />2 <br />9/4/02 <br />925-842-9064 <br />N�M�L- <br />OF.APPI.,ICANT Qrrint) 426 <br />IC <br />TITLE; OF APPLICAN <br />Chevron Products Corppany/D.R. Leri <br />Retail ESH Specialist <br />U.57 FACILITY NUMBED Tv loc-1 wo *,,10 4N, <br />1998 UPGRADE CERTIFICATE NUMBER (For local u;cnniv) 429 <br />rcv icrd1171 Fora",rN! SWRCP Forvn A <br />