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Q� <br /> T FIED PROGRAM CONSOLIDATED FOY DS 0\ / <br /> TANKS A-4 �(1 <br /> UNDERGROUND STORAGE TANKS-FACILITY L - <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 FACII.ITY NAME or DBA-Doing Business As) 3. 1 FACILITY <br /> ID <br /> 1. <br /> ARCO Facility No.2076 �,�l <br /> NEAREST CROSS STREET 4o1. FACILITY OWNER TYPE [:14.LOCAL AGENCY/DISTRICT* 402. <br /> HWY/Kettleman ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION [13.FARM ❑5.COMMERCIAL 4o3. ❑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. s 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 /> 4 ❑Yes ®No <br /> U. 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 4oy <br /> P.O.Box 6038 <br /> CITY 410. 1 STATE ZIP CODE 412. <br /> Artesia CA 90702-6038 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME ata. PHONE ats. <br /> BP West Coast Products LLC 800-525-5857 x6233 <br /> MAILING OR STREET ADDRESS 416. <br /> P.O.Box 6038 <br /> CITY 411 STATE 418. 1 ZIP CODE 419. <br /> Artesia CA 90702-6038 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- FG-F471 1 4 6-1 5 1 Call(916)322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(S) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑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 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I frtify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATUREF PLIC DATE 424. PHONE 425. <br /> 07/13/2005 800-525-5857 x6233 <br /> NAME OF ICANT(print) 426. TITLE OF APPLICANT 427. <br /> John Sche a Environmental Compliance Specialist <br /> STATE UST FACILITY 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)-1/2 http://www.unidocs.org Rev.02/16/00 <br />