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UN' 'D PROGRAM CONSOLIDATED FORM TANKS UNDERGROUND STORAGE TANKS - FACILITY S Z (one page per site) I TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE /a 6 (Check one item only) ❑4.AMENDED PERMIT ❑ 8.TANK REMOVED 111 ❑6.TEMPORARY SITE CLOSURE 400 ME I. FACILITY/SITE INFORMATION 2 1DL° BUSINESS NAME(Same as FACILITY NAor DBA-Doing Business As) ; FACILITY ID# 1 JI ARCO STATION#595* FA0003630 NEAREST CROSS STREET FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT* HWY 99 401 ® 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE ❑3.PARTNERSHIP GAS STATION 4oz ❑ 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 7.FEDERAL AGENCY TOTAL NUMBER OF TANKS IS facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) 4 404 ❑ Yes ® No 405 MANAGER 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE qog MADELfNE SCANNAVINO MAILING OR STREET ADDRESS 409 5463 CHEROKEE CITY 410 STATE 411 ZIP CODE 412 STOCKTON CA 95205 PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP 1:15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 BP WEST COAST PRODUCERS LLC MAILING OR STREET ADDRESS 416 4 CENTERPOINTE DR CITY 417 1 STATE 418 ZIP CODE 419 LA PALMA CA 90623 TANK OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL 1-14.LOCAL AGENCY/DISTRICT 1:16.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ44- 44-000506 Call 916 322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED 1:14.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE 1-15.LETTER OF CREDIT❑ 8.STATE FUND&CFO LETTER M 99.OTHER 1-13.INSURANCE ❑ 6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® L FACILITY ❑2.PROPERTY OWNER E-13.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local ue only) 429 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Y UPCF(1/99 revised)