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is <br /> ur4IFIED PROGRAM CONSOLIDATED FORivi r� <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. pp <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I: <br /> FAC�I:ITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# _ I <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAN E or DBA-Doing Business As) 3' - <br /> ARCO 02133 <br /> BUSINESS SITE ADDRESS 103. CITY Toa. = <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 [14.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> II PROPERTY OR'NER INFORMATION. <br /> 407. PHONE 406 <br /> PROPERTY OWNER NAME <br /> BP WEST COAST PRODUCTS LLC 714-670-3928 <br /> MAILING ADDRESS 409. <br /> P.O. BOX 6038 <br /> a1o. STATE 411• ZIP CODE 412. <br /> CITY - <br /> ARTESIA CA 90702 <br /> III. TANK'OPERATOR;INFORMATIOI�T <br /> 428 <br /> TANK OPERATOR NAME 428-1• PHONE 2 <br /> LAWRENCE WIGHT (209) 478-5552 <br /> 428-3 <br /> MAILING ADDRESS <br /> 2908 BENJAMIN HOLT DR <br /> CITY 4287CA <br /> TE 428-5 ZIP CODE 426-6 <br /> STOCKTON 95207 <br /> '-,TANK. <br /> :O�'NER INF,ORMA <br /> TION <br /> TANK 414. PHONE 415. <br /> COMPLIANCE DEPARTMENT 714-670-3928 <br /> 416. <br /> MAILING ADDRESS <br /> BP WEST COAST PRODUCTS LLC, P.O. BOX 6038 <br /> CITY 417. STATE 416. ZIP CODE 414. <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 EQUALIZATIQN USTSTORAGE FEE ACCOUNT NZTMBER t <br /> Call the State Board of Equalization,Fuel Tax Division, are questions. <br /> TY(TK)HQ 44- 0 4 1 4 6 5 a�1 <br /> notifications and mailings� P. ERNM.E1�LDERILOWNER INFOORMATION <br /> to: 1. ❑ 4.TANK OPERATOR <br /> 423 <br /> Issue permit and send legal notific <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> - <br /> VIY APPLICANTSIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGN URE DATE 424. PHONE 425. <br /> 1-5 - 10, 714-670-3928-:: <br /> APPpC�ANT N rint) 426• APPLICANT TITLE 427 <br /> JENNIFER M. MARINAS Environmental Compliance Specialist <br /> UPCF UST-A Rev.(12/2007) { �¢ , •;,Li_ �' �„ <br />