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U D PROGRAM CONSOLIDATED FORNM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page I of 1 <br /> OF ACTION ❑ 1.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400 <br /> k one item only) ❑4.AMENDED PERMIT (Specify change)Name Change [18.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3, 1 FACILITY <br /> ARCO Facility No.05469 ID# <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4ZENCYIDISTRICT* 402 <br /> Washington ® 1.CORPORATION ❑ 5.COUNTY AGENCY* <br /> BUSINESS N 1.GAS STATION ❑3.FARM El 5.COMMERCIAL 403 ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.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 405. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes ®No <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408 <br /> BP West Coast Products LLC 800-525-5857 x6233 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. Box 6038 <br /> CITY 410. 1 STATE 411. ZIP CODE 412 <br /> Artesia CA 90702-6038 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> 'K OWNER NAME 414. PHONE 415 <br /> Nest Coast Products LLC 800-525-5857 x6233 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O.Box 6038 <br /> CITY 417 1 STATE 41& ZIP CODE 419 <br /> Artesia CA 90702-6038 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT El 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(TK)HQ 44- 0 1 4 1 I 1 4 1 6 1 5 1 Call(916)322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.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 I or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: 1 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 /> fav U 11/22/2004 800-525-5857 <br /> NAME OF APPLICANT(print) 425. TITLE OF APPLICANT 427. <br /> John Schetter Environmental Compliance Specialist <br /> E UST FACILITY NUMBER(Agency use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429 <br /> -.)ata Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />