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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> 70PERATING 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 /> (Check one item onlr) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> 3 (Agency Use Oniti) <br /> BUSINESS NAME(Same as Facilitv Name or DBA-Doing Business As) ; <br /> USA #68153 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 2448 WEST KETTLEMAN LANE LODI <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? ❑ 1.Yes Z 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 1"_ PHONE 4" <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 428-1. PHONE 428-'- <br /> SAME AS PROPERTY OWNER ( ) <br /> MAILING ADDRESS 428-3. <br /> CITY 428-4. STATE 42x-5. ZIP CODE 428-6. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 411. <br /> SAME AS PROPERTY OWNER <br /> MAILING ADDRESS 416• <br /> CITY 417. 1 STATE 41s. ZIPCODE 419. <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 44Call the State Board ol'Equalization.Fuel Tax Division,if there are questions. <br /> 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue pennit and send legal notifications and mailings to: ❑ L FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 42;. <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for-Public Agencies Only) 40t' <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certif3 that the information provided herein is true,accurate,and in full con liance with legal requirements. <br /> APPi T-M ATU DATE 424. PHONE 425. <br /> 11/12/2010 (707) 293-2986 <br /> APPLIC N Tint 426. APPLICANT TITLE 427 <br /> rc Janzen Code Compliance Officer <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />