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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> TYPE OF ACTION ❑ 1.NEW PERMIT <br /> (One form per facility) <br /> ® 5.CHANGE OF INFORMATION <br /> K'her.k nM ern rm(y/ ❑ 7.PERMANENT FACILITY CLOSURE °0p <br /> ❑ 3.RENEWAL PERMIT ❑ b.TEMPORARY FACILITY CLOSURE ❑ 9.'TRANSFER PERMIT <br /> a FACIIdTY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY I <br /> 4 FACILITY IU A _ i <br /> BUSINESS NAME/Some as Foci/iN Name w DBA-Doing Burine.cs(Agency Use Only! _ 1 4 8 0 <br /> Tesoro/USA 68222 <br /> RUSINE$S SITE ADDRESS <br /> 2132 Mariposa Rd. 103 CITY <br /> IM <br /> FACILITY TYPEStOCkton <br /> ® 1.MOTOR VEHICLE FUELINGas <br /> ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands, ❑ I.Yes <br /> ® 2.No <br /> PROPERTY OWNER NAII. PROPERTY OWNER INFORMATION <br /> ME <br /> Tesoro Sierra Properties, LLC Mail Stop: TXI-022 +07 PHONE 108 <br /> MAILING ADDRESS (210)626-6681 <br /> 19100 Rid ewood Parkway <br /> CITY <br /> +10 STATE +�� ZIP CODE <br /> San Antonio +Ix. <br /> TX 78259 <br /> TANK OPERATOR NAME III. TANK OPERATOR INFORMATION <br /> °S8-1 PHONE <br /> Tesoro West Coast Company, LLC Mail Stop: TX1-022 °:.x <br /> MAILING ADDRF..SS (Z 10�626-6681 <br /> 19100 Rid ewood Parkway 4260 <br /> CITY <br /> .xe <br /> San Antonio T -s ZIP CODE °x11 <br /> TX 78259 <br /> ]V. <br /> TANK OWNER NAME TANK OWNER INFORMATION <br /> TesoroWest Coast Com an , LLC Mail Sto : TX1-022 (210)626-6681 <br /> °t5 <br /> MAILING ADDRESS <br /> 19100 Rid ewood Parkway 416 <br /> CITY <br /> San Antonio STATE see ZtP CODE <br /> TX 419 <br /> " <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT <br /> C37.FEDERAL AGENCY 11 5.COUNTY AGENCY® B.NON-GOVERNMENT ❑ 6.STATE AGENCY azo <br /> TY(TK)HQ 44-V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Q 4 $ 6 6 2 <br /> Call the State Board of Equaliratiuq Fuel Tax Division,if there are questions. °x' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue Permit and send legal notifications and mailings to: <br /> ❑ I,FACILITY OWNER Cl 4.TANK OPERATOR 025 <br /> SUPERVISOR OF DIVISION.SECTION,OR OFFICE/Required for Public®gencTANK OWNER ❑ 5.FACILITY OPERATOR <br /> rM <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 cern{ that the <br /> information provided <br /> P NT SIGTURherein is true accurate,and in full com lince with leaIre uiremenb. <br /> APNA � <br /> DATE +x° PHONE +: <br /> APPLICANT NAME nnH S 11/5/2010 559 585-8156 . -w <br /> Sand Edwards R8 APPLICANT TITLE <br /> 427 <br /> Environmental Com liance Administrator .. <br /> UPCF IST-A Rev.(12/2007).1/2 <br /> wsvw.uoidors,org <br /> 01 v Ind <br />