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s iFIED PROGRAM CONSOLIDATED FOi. <br /> UNDERGROUND STORAGE TANK f ` <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® 1.NEW PERMIT ❑ S.CHANGE OF INFORMATION El7.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 4°4. FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> ARCO 02133 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 2908 BENJAMIN HOLT DR 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 /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 40e. <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> MAILING ADDRESS 409. <br /> P.O. BOX 6038 <br /> CITY ato. STATE atl. ZIP CODE alz. <br /> ARTESIA CA 90702 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> LAWRENCE WIGHT (209) 478-5552 <br /> MAILING ADDRESS 429-3 <br /> 2908 BENJAMIN HOLT DR <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> STOCKTON ICA 95207 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> 416. <br /> MAILING ADDRESS <br /> P.O. BOX 6038 <br /> CITY 417. STATE 418. 1 ZIP CODE 419. <br /> ARTESIA ICA 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 1411 14-16 1 5 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <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 e I ormation provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE azs. <br /> 1714-670-3958 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> BRATZO BASAGOITIA Environmental Compliance Specialist <br /> Y�o?9/ <br /> UPCF UST-A Rev.(12/2007) <br />