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O NCq <br /> Ira <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE a00 <br /> (Cheek em nem vtt,) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERhI1T <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY4, FACILITY ID q _ _ 2 / t <br /> q (Agency Use Only) J <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) s, <br /> Tesoro/USA 68154 <br /> BUSINESS SITE ADDRESS lELodi <br /> IN <br /> 2500 W. Lodi Ave.FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 1located on Indian Reservation or 4053.FARM ❑ 4.PROcF.SSOR ❑ 6.OTHER ❑ I.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE a0s <br /> Tesoro Sierra Properties, LLC 253 896-8700 <br /> MAILING ADDRESS 409 <br /> 3450 South 344th Way, Suite 201 <br /> CITY 410. STATE 411- ZIP CODE 412. <br /> Auburn WA 98001-5931 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 426-1 PHONE 4zs-z. <br /> Tesoro West Coast Company, LLC (253) 896-8700 <br /> MAILING ADDRESS T55- <br /> 3450 South 344th Way, Suite 201 <br /> CITY 42x.4. STATE ua-s. ZIP CODE 42M <br /> Auburn WA 98001 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Tesoro West Coast Company, LLC (253) 896-8700 <br /> MAILING ADDRESS 416. <br /> 3450 South 3440 Way, Suite 201 <br /> CITY 411. STATE alt. 21P CODE 419, <br /> Auburn WA 98001 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY azo. <br /> ❑ 7.FFDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK) HQ 44- Q 4 j 57-6 16 1 2 1 Call the State Board of Equalization,Fuel Tac Division,if there are questions. 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send le I notifications and mailings to: ❑ 4.TANK OPERATOR 421 <br /> P Ba gs ❑ LFACILITY OWNER <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required firr Public Agencies Only) <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: [certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> ^PLICANJ SIGNAWJJE I DATE, 474 1 PHONE +2 <br /> S 8/3/2009 559 585-8156 <br /> APPLICANT N E(prinQ 4ze APPLICANT TITLE r <br /> Sand Edwards Environmental Compliance Administrator i' <br /> UPCF UST-A Rev.(122007)-12 w .unidoes.org <br />