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4FIED PROGRAM CONSOLIDATED FOi <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 /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> ` ACII. I1�tFORMATION <br /> F ' <br /> ., <br /> TOTAL NUMBER OF LISTS AT FACILITY a°a' FACILITY ID# <br /> 3 (Agency Use Only) I I 7 - <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 STOCK-TON <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 /> lT PRQFERTY OR'NER'Ii�FORMATION <br /> PROPERTY OWNER NAME 407• PHONE 409. <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 /> OPERAT: ORIVIA►.TXON <br /> TANK OPERATOR NAME 425-1. PHONE 428-2 <br /> LAWRENCE WIGHT (209) 478-5552 <br /> 426-3 <br /> MAILING ADDRESS <br /> 2908 BENJAMIN HOLT DR <br /> CITY 4284 STATE 428-5 ZIP CODE 42e-6 <br /> STOCKTON CA 195207 <br /> N TANK OWNER INFORMATIOl�f i <br /> TANK OWNER NAME 41a- PHONE als. <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> 416. <br /> MAILING ADDRESS <br /> P.O. BOX 6038 <br /> CITY 417. STATE ala. ZIP CODE 419. <br /> ARTESIA CA 190702 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> VBOARD OF'I�Qi7AY;IATIOT IIST STOitAGE FEE ACCOUNT NUMBER <br /> ... _.._. <br /> TY(TK)HQ 44- 1 0 4 1 4 6 5 Call the State Board of Equalization,Fuel Tar Division,if there are questions 421' <br /> 64 <br /> VI PERNIIT)EtOLDER INIH'ORMiTIQN <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 /> CERTIFICATION: I certifythat I ormation provided herein is true,accurate,and in full com Iia 4. wi ih IeEal re <br /> uirements. <br /> APPLICANT SIGNATURE p N 425. <br /> zz ' <br /> 714-670-3958 <br /> APPLICANT NAME(print) 426. APPLIC T TITLE 427 <br /> BRATZO BASAGOITIA Environmental Compliance Specialist <br /> YS6�gi <br /> UPCF UST-A Rev.(12/2007) <br /> I <br />