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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Clieck one item onl) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 414. FACILITY ID 4 t. <br /> 3 (Agency Use Only) - - <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> USA#68153 <br /> BUSINESS SITE ADDRESS 103. CITY too. <br /> 2448 WEST KETTLEMAN LANE LODI <br /> FACILITY TYPE ® L 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? ❑ L Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 40& <br /> TESORO REFINING & MARKETING COMPANY ) <br /> MAILING ADDRESS 409- <br /> 1361 LA VISTA AVE. <br /> CITY 410 STATE 411. ZIP CODE 412 <br /> CONCORD CA 94521 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 421-1 PHONE 42s-2 <br /> SAME AS PROPERTY OWNER <br /> MAILING ADDRESS 428-3. <br /> CITY 4264. STATE 428-5. ZIP CODE 42s-6. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 41= <br /> SAME AS PROPERTY OWNER ( ) <br /> MAILING ADDRESS 416. <br /> CITY 417. STATE 418. ZIP CODE 419 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44_ Call the State Board o1 Equalization.Fuel Tax Dig ision.if there are questions. 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue pennit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required f6r Public Agencies Only) 406. <br /> VIL APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full com liance with legal requirements. <br /> AI PSL W- T S ATU DATE 424. PHONE 425. <br /> - <br /> 11/12/2010 (707) 293-2986 <br /> APPLIC N lint i 426. APPLICANT TITLE 427 <br /> rc Janzen Code Compliance Officer <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />