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Milk <br /> UNIFIED PROGRAM CONSOLIDATED FORM RECEIVED <br /> UNDERGROUND STORAGE TANKE: <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION nnII <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT F Y CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERM"'r ' NMENTAL HEALTH <br /> GES <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> 3 (Agency Use Only) 7 -7 1'3 <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 ® 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 428-3 <br /> 3212 N.CALIFORNIA ST. <br /> CITY 428-4 1 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 714-670-3928 <br /> MAILING ADDRESS 416. <br /> COMPLIANCE DEPARTMENT,P.O.BOX 6038 <br /> CITY 417. 1 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 0 1 4 1 1 1 4 1 6 1 5 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. <br /> 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 /> Viz,,n 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 re vtfrements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 6;�, 425. <br /> 714-670 � 28 <br /> APPLICANT NAME(print) OA 426• APPLICANT TITLE 427 <br /> RICHARD GOSSETT ENVIRONMENTAL COMPLIANCE SP F&IST <br /> Arco 02186,Belshire Environmental Services <br />