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l <br />M <br />6 vl2 wt3101 _ <br />UNIFIED PROGRAM (UP) FORM <br />UNDERGROUND STORAGE TANKS - FACILITY <br />one pace per site Pae of <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br />(Check one item only) [12. INTERIM PERMIT [14. AMENDED PERMIT ❑ &TEMPORARY SITE CLOSURE ❑ 8. TANK REMOVED 400 <br />I. FACILITY / SITE INFORMATION <br />BUSINESS NAME (Sam asFACILITY NAME ornea) 3 <br />FACILITY <br />1 441 <br />1 <br />O <br />O <br />1 <br />Tesoro West Coast Company, LLC USA CC#68154 <br />( <br />NEAREST CROSS STREET 401 <br />FACILITY OWNER TYPE LJ 4. LOCAL AGENCY/DISTRICT' <br />2500 W LODI AVE LODI, CA 95240 <br />® 1. CORPORATION ❑ 5. COUNTY AGENCY' <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY' <br />BUSINESS E 1. GAS STATION El 3. FARM Ej 5. COMMERCIAL <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR [16. OTHER <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' <br />403 <br />402 <br />TOTAL NUMBER OF TANKSIs <br />facility on Indian Reservation or <br />'N owner of UST is a public agency: name of supervisor of division, section or <br />REMAINING AT SITE <br />trusbands? <br />office which operates the UST (This is the contact person for the tank records.) <br />4 404 <br />❑ Yes ® No 405 <br />406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />Kris Mon c <br />PHONE p 16 _-77? _ iTe <br />! C !O <br />,T"MSierraPiD; E60 <br />-253-8968700' <br />MAILING OR STREET ADDRESS409 <br />0 <br />3450 SOUttt " Wa-Soffa nD`o. 201 100 Co 11¢pe iOW� i , ( 1 <br />CITY 410 STATE 411 <br />L A fn at f-� <br />ZIP CODE 412 <br />Aubum _ Q r WA <br />98001-5939- <br />PROPERTY OWNER TYPE 1. CORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY /DISTRICT 8. STATE AGENCY <br />❑ 3. PARTNERSHIP [15. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />111. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />�ierrA, Prop&4'/l S (lam <br />PHONE 415 <br />9q6 8�cso <br />Same as owner_ e���o <br />L53 <br />416 <br />MAILING OR STREET ADDRRIESS.� <br />�J <br />).15 0 J, 0 <br />CITY 417 1 <br />v �r� <br />STATE .416 <br />V <br />ZIP CODE 419 <br />TANK OWNER TYPE 1. CORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY / DISTRICT Lj 6. STATE AGENCY 420 <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY K HQ 44- I.j 6 ja Call 916 322-9669 'If questionsarise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />514 KATE <br />METHOD(s) ® 1. SELF-INSURED [14. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />® 2. GUARANTEE ❑ 5. LETTER OF CREDIT [18. STATE FUND & CFO LETTER ❑ 99.OTHER: <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 422 <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and mailing. 423 <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 <br />VII. APPLICANT SIGNATURE <br />Certification - I nformatbn PrVded he 'n is truand accurate to the best of my knowledge. <br />SIGNATOR A <br />Fes; <br />DATE: 4-23-07 424 <br />PHONE s -8'00425 <br />NAME OF APPLICANT (print) Cindy Hughes Madrid 426 <br />1 TITLE OF APPLICANT: General manager retail services 427 <br />OFFICIAL USE ONLY <br />DATE RECEIVED <br />COPA <br />PA <br />DISTRICT/INSPECTOR <br />STATE UST FACILITY NUMBER ata <br />1998 UPGRADE CERTIFICATE NUMBER 429 <br />UP FORM (1/2000 Version) 1 Formerly SWRCB Form A <br />SBC UST-A.doc <br />