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0 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) I <br /> TYPE OF ACTION 1.NEW PERMIT 0 5.CHANGE or wroitmxrm 0 7.PERMANEW FACILITY CLOSURE 400. <br /> (rheck one item wdy) 3_RENEWAL PERMIT [] 6.TEMPORARY FACILITY CLOSURE [:19.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> IVI'AL NUMBER OF USTS AT FACILITY FACILITY 0# t. <br /> 3 (Agermy Use OR61) <br /> BUSINESS NAME(Saw as Facility Nmw or DM-Doft lbainess AS) 3. <br /> Chevron Station#96171 <br /> BUSINESS SITE ADDRESS 103, CITY 104. <br /> 6633 Pacific Ave Stockton, CA 95207 <br /> FACILrryTyPF M I.MOTOR VEHICLE FUELING [3 2.PURL DISTRIBUTION 403. Is the facility located on Indian Reservation or 465, <br /> 0 3.FARM [3 4.PROCESSOR [1 6.OTHER rmst tater? El 1.Yes 0 2.No <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407- 1 PHONE 408. <br /> Lincoln Properties LTD (925)842-9002 <br /> MAtl.NGADDRI--'SS 4W. <br /> 374 Untmin Center STATE CITY 4n. I 7ip coDr. 412, <br /> Stockton CA 95207 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-I. PHONE 428.2. <br /> Chevron Products Corn eany, Attn:HESPermit Desk L2375 (925)842-9002 429-3. <br /> MAILING ADDRESS <br /> P.O.Box 6004 <br /> CITY 42". 1 STATE zip CODE QnZ. <br /> San Ramon CA 94583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNERNAW 414. PHONE 415. <br /> Chevron Products Com Eairiy, Attn:RES Permit Desk V3 75 (925)842-9002 41& <br /> MAILING ADDRESS <br /> P.O.Box 6004 <br /> CITY 417. T-§T-An 418. ZIP CODE+ 419. <br /> San Ramon I CA 94583 <br /> OWNER TYPE: 1.CORPORATION ❑ 2.COUNTY AGENCY [13,STATE AGENCY 4". <br /> ❑ 4,FRI)ERAL AGENCY ❑ 5.NON-GOVERNMENT 0 6.LOCAL AGENCYIDISTRICT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1_9�31 19 1 1 1 3__I Call the State Board of Equali7*ion,Fuel Tax Division,if there arc questions. 421. <br /> VI.PERMIT HOLDER]INFORMATION <br /> Issue permit and scnd IqW w9fications and mailings to: CI 1.FACILITY OWNER 4,TANK OPERATOR 4z. <br /> 3,TANK OWNER Q 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredfar PubficiVwies OW 4N. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION. I cerci that the information provided herein is crua,secure%and in full S2pplissce with legal Mquirements. 42S,- <br /> APPLICANT SIGNATURE DATE ON <br /> SID XARV9MZ 01/12/2009 925-842-9002 <br /> APPLICANT NAME(print) 42(L APPLICANT TITLE 427 <br /> Chevron Products Company/FRED MAWI'INEZ Retail HES Permit Desk <br /> 1UPCF UST-A Rev.(12/2007) <br /> OTO[n VM13V oaavaa!) zeso US 996 yva or:60 6002/zz/zo <br />