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FROM : J.Schetter PHONE NO. : 5306667692 Mar. 21 2005 04:53PM P2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS C4�D 10 5 <br /> UNDERGROUND STORAGE TANKS - FAULITY(One page per site) 3 Page 1 of 1 <br /> ITE <br /> CYPN OF ACTION ❑1.NEW PERMIT (�S.RENEWAL PERMIT ®5.CH+NGF:OF INFURMA'1'ION ❑� pER1�4A0 8.'I'Y K REMOVED ED 400 <br /> ❑8.'!'ANTC REMOV1iD <br /> (Check one item only) ❑4 AMENDED PERMIT (SP-10Y chan8c). j�Iame Change_-.--.- <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> FACILITY 1. <br /> BUSINESSNAME(SaneasFAC'tLITYNAT or DBA-lkl/busin�'/�s1 J. ID#ARCO FacilityNo.04932 /j�� ,At_ FACILITY OWNER TYI'1; ❑4,LOCAL A , CY/DISTRIC T" 401 <br /> NEARE51'CROSS STREET [D 1.CORPORATION ❑5.COUNTY AGENCY" <br /> Hardin,Way/Center Street aoa. 2.INDIVIDUAL ❑6.STATE AGENCY" <br /> BUSINESS k.GAS STATION 3.FARM ❑5.CON1tvilrRC;IAL ❑ 7_FEDERAL AGENCY" <br /> 3.PARTNE1cSTiIP � <br /> TYPE p 2_DISTRIBUTOR ❑4.PROCESSOR Q 6.OTHER ❑ I v 406. . <br /> SS facilit 011 Indiatl Reservation a6S If owner of US f is a public a enc :name of ui rvisoi of division,section 0' <br /> TO'l'AI,NUMBER OF TANKS 404 y office which operates the(IST. (ibis is tha contact person for the tank records.) <br /> RTiMATNING AT SITE or trust lands? <br /> 03 [J Yes ®No <br /> IT. PROPERTY OWNER INFORMATION <br /> a=PHONE �PROPERTY OWNER NAME <br /> BP West Coast Products LLC X6233 <br /> 409. <br /> MA)],TNCi 012 STREFT ADDRESS <br /> P.O_Box 6038 <br /> CITY aro. MCA <br /> TE '� �90702 <br /> CO <br /> DE 412. <br /> Artesia <br /> PROPERTY OWNER TYPE 0 1.CORPORATION Lj 2.INTNVTDUAL ❑4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> M.TANK OWNER INFORMATION <br /> TANK OWNFR NAME 414. PHONE 415. <br /> BP West Coast Products LLC800-525-5857X6233 <br /> MAILINC*OR STREET ADDRESS 416. <br /> P.O.Box 6038 <br /> CITY 41) STATE 418. ZIP CODE 419. i <br /> .Artesia CA 90702-6038 <br /> TANK OWNER TYPE 1.CORPORATION ❑2,INDIVIpi IAT. 4.LOCAL AGE.NCY/1?ISTRTCT U 6.STATE AGENCY 420. <br /> ©3.PARI_NERSHIP []5.COUNTY AGF NCY ❑7.FEDERAL AGENCY <br /> TV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)H2 4.4- 0 4 1 4 6 5 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) a 1,SE1,I;.INSIA2E"D [14.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MBCl ANISM 422. <br /> ❑2.GUARANTEE ❑5.LMTER OF CREDIT ❑8.STATE FUND&CFU I.F.TrF;R ❑99.OTHER: <br /> []3 INSURANCE: ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VL LEGAL NOTIFICATION AND MAHANG ADDRESS <br /> 'Chock one box to indicate which address should be used for legal notification and mailing. <br /> I.egnl notificaionc and mailing.:will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.r-Acii.1TY 0 2. PROPEffrY OWNER ®3.TANK OWNER 423, <br /> V11.APPLICANT SIGNATURE <br /> Catification: I ccrtiq that the information provided herein is true and actuate to the best of my knowle4p, <br /> STGNATITRE OF PP CANT DATE- 424. PiION1G 425. <br /> 03/21/2005 800-525-5857 X6233 <br /> NA1vkF OFA .T ANT(print) 426 TTTT.F.OF APPLIC..ANT 127. <br /> John Scher Environmental Compliance Specialist <br /> STATE UST P.4,61LITY N17MSER(ngaxyaaeonty) <br /> 428. 19991)KA ADE CER'1'IFICAT8 NUMBER(Agamyux only) 429. <br /> (Sm Data Fitment),above, <br /> UPCF Hwfwr"(1/99)-1/2 halve/www.trnidomerg Rev.02/16/00 <br />