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ru 4 1 sir y CIV� <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> RECEIVED <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INF <br /> (One form per facility) i-� <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMAIF 4°Q <br /> (Check one item only) ® 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT � ti <br /> I. FACILITY INFORMATION F ' <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID# _ <br /> 2 (Agency Use Only) `Sq ✓ 0,9 <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) N NV! U/j� 3. <br /> Chevron Station# 209167 �crN' '�vMF�ovN <br /> BUSINESS SITE ADDRESS 103. CITYTMST 104. <br /> 1234 Yosemite Ave Manteca, CA 95336 <br /> FACILITY TYPE Z 1.MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or aos. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 40a <br /> Chevron Products Company, Attn:HES Permit Desk L2375 (925)842-9002 <br /> MAILING ADDRESS 409. <br /> P.O. Box 6004 <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> San Ramon CA 94583 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4287PHONE 428-2. <br /> Chevron Products Company, Attn:HES Permit Desk L2375 (925)842-9002 <br /> MAILING ADDRESS 428-3. <br /> P.O. Box 6004 <br /> CITY 428-4. STATE 428-5. ZIP CODE 428-6. <br /> San Ramon CA 94583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Chevron Products Company, Attn:HES Permit Desk L2375 (925)842-9002 <br /> MAILING ADDRESS 416. <br /> P.O. Box 6004 <br /> CITY 417, STATE 418. ZIP CODE 419. <br /> San Ramon CA 94583 <br /> OWNER TYPE: Z 1.CORPORATION ❑ 2.COUNTY AGENCY ❑ 3.STATE AGENCY 420. <br /> ❑ 4.FEDERAL AGENCY ❑ 5.NON-GOVERNMENT ❑ 6.LOCAL AGENCY/DISTRICT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 13 1 1 19 1 1 1 3 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423. <br /> Z 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com liance with le al requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> TRE(DXAl�`II.NEZ 01/14/2009 925-842-9002 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Chevron Products Company/FRED MARTINEZ Retail HES Permit Desk <br /> UPCF UST-A Rev.(12/2007) <br />