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� I <br /> _ IED PROGRAM CONSOLIDATED FOIN <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY E: INFORMATION ��pCV���ffjj <br /> (One form per fadility <br /> TYPE OF ACTION ® 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 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) c <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) <br /> ARCO 02186 <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> 3212 N. CALIFORNIA ST. STOCKTON <br /> FACILITY TYPE ® I.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 714-670-3958 <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 428-3 <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 /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> MAILING ADDRESS 416 <br /> P.O. BOX 6038 <br /> CITY 417. STATE 418. ZIP CODE 419 <br /> ARTESIA CA 90702 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY Z 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 4 1 4 6 5 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 in madon provided herein is true,accurate,and in full com liance with le al requirements. <br /> APPLICANT SIGNATURE DATE ata. PHONE azs. <br /> 714-670-3958 <br /> APPLICANT NAME(print) 426. APPLIfCANT TITLE 427 <br /> BRATZO BASAGOITIA Environmental Compliance Specialist <br /> C150�?3 <br /> UPCF UST-A Rev.(12/2007) <br />