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UED PROGRAM CONSOLIDATED FOR TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page 1 of 5 <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5OHANGE OF IN <br /> ❑ 7.PERMANENTLV CLOSED SITE <br /> ® 8.TANK REMOVED <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only qoo <br /> ❑15 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILIT9 NAME or DFA-Doing Business As) 3 FACILITY ID# 1 <br /> Tosco#256981-Pacific 76 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> 40 ® 1.CORPORATION ❑ <br /> NEAREST CROSS STREET 5.COUNTY AGENCY" <br /> 4707 Pacific Avenue Mach Lanes STOCKTON 6.STATE AGENCY` <br /> BUSINESS ®1.GAS STATION 3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑7.FEDERAL AGENCY" aoz <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑ <br /> Is facility on Indian Reservation or "If owner of UST is a public agency:name of supervisor of division,section or ofllce <br /> TOTAL NUMBER OF TANKS Is fa a ds7 which operates the UST(This is the contact person for the tank records.) <br /> REMAINING AT SITE 406 <br /> 2 404 ❑ Yes ® No 405 <br /> 11. PROPERTY OWNER INFORMATION <br /> 407 PHONE 408 <br /> PROPERTY OWNER NAME <br /> TOSCO CORPORATION - 409 <br /> MAILING OR STREET ADDRESS <br /> P.O. Box 52084 410 1 STATE 411 ZIP CODE 412 <br /> CITY AZ 85072-2084 <br /> Phoenix <br /> PROPERTY OWNER TYPE 1.COF2PORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY413 <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7. FEDERAL <br /> III.TANK OWNER INFORMATION <br /> Ir" 414^riei q)q PHONE <br /> 415 <br /> TANK­­OWNERNAME 925-277-2319 <br /> TOSCO CORPORATION Ota <br /> MAILING OR STREET ADDRESS <br /> P.O. Box 52084419 <br /> an STATE 41e ZIP CODE <br /> CITY AZ 85072-2084 <br /> Phoenix <br /> TANK OWNER TYPE ®1.CORPORATION [j2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT -0-6.STATE AGE 420 <br /> ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - <br /> 421 <br /> TY TK HO 44- 0 3 6 2 4 4 <br /> Call 916 322-9669 if questions arise <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ® 1.SELF-INSURED ❑4. SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(S) ❑2.GUARANTEE ❑ 5. LETTER OF CREDIT ❑8. STATE FUND&CFO LETTER ❑ 99.OTHER: 422 <br /> ❑3. INSURANCE [16. EXEMPTION ❑ 9.STATE FUND&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to Indicate which address should be_ua.d for legal notifications and mailing. <br /> 423 <br /> Legal notifications and mailings will be sent to thee tank owner unless box 1 or 2 is checked. C] 1.FACILITY C3�. PROPERTY OWNER ®3.TANK OWNER <br /> VII. APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. 424 PHONE 425 <br /> DATE (g25) 313-9700 <br /> SII TURE OFAPPLI�ANT 3/17/00 <br /> 4zT <br /> E F ICANT(print) <br /> ata TITLE OF APPLICANT <br /> Za Agent for Tosco Oiga Gianino (of RHL Design Group, Inc.) 449 <br /> STATE UST FACILITY NUMBER(For local use only) 42B 1998 UPGRADE CERTIFICATE NUMBER(For local use only) <br /> • Formerly SWRCB Form A <br /> UPCF (1/99 revised) <br />