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-- -;r 1 y <br /> U7TFIED PROGRAM CONSOLIDATED FOR.I -� <br /> UNDERGROUND STORAGE TANK =' <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per faculty) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# t <br /> 3 (Agency Use Only) 6 <br /> BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) 3. <br /> ARCO 02186 <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> 3212 N. CALIFORNIA ST. STOCKTON <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> BP WEST COAST PRODUCTS LLC 714-670-3928 <br /> MAILING ADDRESS 409. <br /> P.O. BOX 6038 <br /> CITY 410. STATE 411 ZIP CODE 412, <br /> ARTESIA CA 90702 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> KHAI QUANG VO (209) 941-2694 <br /> MAILING ADDRESS 4283 <br /> 3212 N. CALIFORNIA ST. <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> STOCKTON � CA 95204 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415. <br /> COMPLIANCE DEPARTMENT 714-670-3928 <br /> MAILING ADDRESS 416 <br /> BP WEST COAST PRODUCTS LLC, P.O. BOX 6038 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> ARTESIA � CA 90702 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 O 4 1 4 16 1 5 F Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPL ANT SIGNATURE DATE 424 PHONE 425. <br /> 714-670-3928 <br /> APPLIC T N Tint) 426. APPLICANT TITLE 427 <br /> JE W IFER M. MARINAS Environmental Compliance Specialist <br /> UPCF UST Rev.(12/2007) <br />