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ED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page 1 of 1 <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (specify change) Name Change ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busin s ) 3. FACILITY <br /> ARCO Facility No.04932 I b ID# <br /> NEAREST CROSS STREET 4o1. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* <br /> Hardin Way/Center Street ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION El 3.FARM El 5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY; <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY' <br /> TOTAL NUMBER OF TANKS 404_ Is facility on Indian Reservation 405. *If owner of UST is a public agency: name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 03 ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> BP West Coast Products LLC 800-525-5857 X6233 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O.Box 6038 <br /> CITY 410. STATE 411 ZIP CODE 412. <br /> Artesia I CA 90702-6038 <br /> PROPERTY OWNER TYPE MIXORPORATION EITINDIVIDUAL 4.LOCAL AGENCY/DISTRICT Ej 6.STATE AGENCY 411 <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> BP West Coast Products LLC 800-525-5857 X6233 <br /> MAILING OR STREET ADDRESS 416- <br /> P.0.13ox 6038 <br /> CITY 417, STATE 418. ZIP CODE 419. <br /> Artesia I CA 90702-6038 <br /> TANK OWNER TYPE ®1.CORPORATION ❑2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 4 1 1 1 4 1 6 1 5T Call(916)322-9669 if questions arise 42,. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE [16.E30EMPTION ❑9.STATE FUND&CD <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 I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certil that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF P CANT DATE 424. 1 PHONE 425, <br /> Q,12f 03/21/2005 800-525-5857 X6233 <br /> NAME OF AP I ANT(print) 426. TITLE OF APPLICANT 427, <br /> John Schetter iEnvironmental Compliance Specialist <br /> STATE UST kAotILITY NUMBER(Agency use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1R http://www.unidoc&org Rev.02/16/00 <br />