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Now <br /> ,HIED PROGRAM CONSOLIDATED FOI 0 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> I (One form per facility) <br /> TYPE OF ACTION 0 1.NEW PERMIT El 5.CHANGE OF INFORMATION [1 7.PERMANENT FACILITY CLOSURE 400.. <br /> (Check one item only) El 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> - :- <br /> XI FAC :1 <br /> tw. -T10N!;;:1 <br /> TOTAL NUMBER OF USTs AT FACILITY 404" FACILITY ID# <br /> 3 (Agency Use Only) J. <br /> BUSINESS NAME(Same as FACILITY NANffi or D13A-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 [1 4.PROCESSOR ❑ 6.OTHER Trust lands? E]Yes 0 No <br /> :.J <br /> a <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 /> j <br /> :.". ­;"I.,jw "N <br /> F- <br /> ON'B'-T' <br /> 4. <br /> TANK OPERATOR; . NAME 428-1- PHONE 429.2 <br /> LAWRENCE WIGHT (209) 478-5552 <br /> 429-3 <br /> MAILING ADDRESS <br /> 2908 BENJAMIN HOLT DR <br /> CITY 429-4 STATE 428-5 ZIP CODE 428-6 <br /> STOCKTON CA 95207 <br /> .TION <br /> 414. PHONE 415 <br /> TANK OWNER NAME <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 416 <br /> MAILING ADDRESS <br /> P.O. BOX 6038 <br /> CITY 417. STATE 418, ZIP CODE 419. <br /> ARTESIA CA 90702 <br /> OWNER TYPE: [1 4.LOCAL AGENCY/DISTRICT F1 5.COUNTY AGENCY El 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 9.NON-GOVERNMENT <br /> V. <br /> BOARWO EQi7 <br /> AdkhoN IIST -V C ER!::!:. <br /> TY(TK)HQ 44- 1 01 411 1 4 16 151 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI PERMIT FOLDER 0 qt­ ! :. <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER [1 4.TANK OPERATOR <br /> 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> 177777=! 7 <br /> CERTIFICATION: I certify that RLOrmation provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE 424. 1 PHONE 425. <br /> 714-670-3958 <br /> APPLICANT NAME(print) 426. APPLICJkNT TITLE 427 <br /> BRATZO BASAGOITIA Environmental Compliance Specialist <br /> Ysaggi <br /> UPCF UST-A Rev.(12/2007) <br /> w <br />