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• �w <br /> XIED PROGRAM CONSOLIDATED FOI. j <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® 1.NEN 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 /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404, 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 to3. CITY loa. <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 /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 408. <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> 409. <br /> MAILING ADDRESS <br /> P.O. BOX 6038 <br /> CITY ato. STATE 411. ZIP CODE 412. <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 /> 428-3 <br /> MAILING ADDRESS <br /> 2908 BENJAMIN HOLT DR <br /> CITY428-4 STATE 428-5 ZIP CODE 428-6 <br /> STOCKTON CA 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 <br /> a17. STATE 418. ZIP CODE 419. <br /> ARTESIA CA 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- 0 14 1 1 1 4-F6--175 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: E] 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 425. <br /> f 714-670-3958 <br /> APPLICANT NAME(print) 426• APPLICANT TITLE 427 <br /> BRATZO BASAGOITIA Environmental Compliance Specialist <br /> YSU?,?i <br /> UPCF UST-A Rev.(12/2007) <br />