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ARCO Fac . No. 6020 <br /> BCE #3518 . 2 <br /> UNIFIED PROGRAM CONSOLIDATED FORM is W �\t� \� <br /> UNDERGROUND STORAGE TANK JAIA <br /> OPERATING PERMIT APPLICATION - FACILITY INF J TI� , <br /> (One form per facility) WL <br /> TYPE OF ACTION ❑ I.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 /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> Three (3) (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3• <br /> ARCO AM/PM <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1711 E . Yosemite Avenue Manteca <br /> FACILITY TYPE g I.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? ❑ I.Yes ❑ 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408. <br /> &ii*&=Gha4BP West Coast Products LLC <br /> 415 725-0419 <br /> MAILING ADDRESS 4 Centerpointe Drive 409. <br /> CITY 410. STATE all. ZIP CODE alz. <br /> La Palma Cps 90623-1066 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> Rima 'h-a-dha - BP West Coast Products LLC ( 415 )725-0419 <br /> MAILING ADDRESS 428-3. <br /> 4 Centerpointe Drive <br /> CITY 428-0, STATE 428-5. ZIP CODE 428-6. <br /> La Palma CA 90623-1066 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ala. PHONE 415. <br /> Rima --Chadha-___7 BP West Coast Products LLC ( 415 ) 725-0419 <br /> MAILING ADDRESS 416. <br /> 4 Centerpointe Drive <br /> CITY 417. STATE 418. ZIP CODE a19. <br /> La Palma CA 90623-1066 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY [d8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423. <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> /// -.� 6) 503 475-2982 <br /> APPLICANT NAME(pri t) 426. APPLICANT TITLE 42 <br /> Ruth Ha Environmental Compliance Specialist <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />