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a Affil <br /> IFIED PROGRAM CONSOLIDATED FOIM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) [14.AMENDED PERMIT (Specify change)_Name Change [18.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sane as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> Facility No. 09600 /o?.SOAl <br /> IDH <br /> NEAREST CROSS STREET 1401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402, <br /> N.Wilson Way/East Hardin Way S 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS S 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.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 S No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408, <br /> Best California Gas LTD 562-921-3581 <br /> MAILING OR STREET ADDRESS 409. <br /> 13539 E.Foster Road c/o B.Berkett <br /> CITY 410 1 STATE 411. ZIP CODE 4¢, <br /> Santa Fe Springs CA 90670 <br /> PROPERTY OWNER TYPE 1.CORPORATION Ej 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY 413. <br /> X 3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414, PHONE 415. <br /> BP West Coast Products LLC 714-670-5402 <br /> MAILING OR STREET ADDRESS 416. <br /> P.O.Box 6038 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Artesia CA 90702-6038 <br /> TANK OWNER TYPE 1.CORPORATION Lj 2.INDIVIDUAL Lj 4.LOCAL AGENCYIDISTRICT Lj 6.STATE AGENCY 420. <br /> [-13.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) S 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [:110.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE [IS.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. ❑ L FACILITY ❑2. PROPERTY OWNER S 3.TANK OWNER 423_ <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424. 1 PHONE 425. <br /> s -.e Al Awre - 12/27/01 714-670-5402 <br /> NAME OF APPLICANT(print) a26 TITLE OF APPLICANT 427. <br /> Carlos Rodriguez Environmental Compliance Specialist <br /> STATE UST FACILITY NUMBER(Agency use only) 429. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF hwf2730(1/99)-36/37 http://www.unidoes.org Rev.04/17/00 <br />