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a �IFIED PROGRAM CONSOLIDATED FQ9 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION [11.NEW PERMIT [13.RENEWAL PERMIT ®5.CHANGE OF INFORMATION 7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change)Name Change ❑8 <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> .r 1 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. 1 FACILITY <br /> ID# Tl' � 1 I' <br /> ARCO FacilityNo.06020 E ViR L <br /> NEAREST CROSS STREET t111 CS(TO(}fi 401. FACILITY OWNER TYPE 4.L GENCY/DISTRICT* 402. <br /> Highway 99 ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS N 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [:16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405• *If owner of UST is a public agency:name of supervisor of division,section or 406• <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> BP West Coast Products LLC (800)525-5857 x6233 <br /> MAILING OR STREET ADDRESS 409. <br /> P.O.Box 6038 <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Artesia CA 90702-6038 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415. <br /> BP West Coast Products LLC (800)525-5857 x6233 <br /> MAILING OR STREET ADDRESS 416. <br /> P.O.Box 6038 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Artesia CA 90702-6038 <br /> TANK OWNER TYPE ® 1.CORPORATION [12.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 0 4 1 1 1 4 1 6 1 5 1 Call 916 322-9669 if questions arise 421. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certify that the infor"on provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT,-- DATE 424. PHONE 425. <br /> _ 04/13/2004 (800)525-5857 x6233 <br /> N F A PLICA T(print) 426. TITLE OF APPLICANT az7. <br /> Omar Vasquez Company Rep. <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwre-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />