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UNIFIED PROGRAM CONSOLIDATED FORM > <br /> YANKS <br /> UNDtRGROUND STORAGE TANKS - FACIL,fY OCT I 2V <br /> (one Rl'I � J,iUUllp I <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) [14.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY.ID# P T O O O n 7 7 9 1 <br /> ARCO 06080 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT* <br /> 1-5 E 1.CORPORATION ❑ 5.COUNTY AGENCY* <br /> BUSINESS E 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 404 ❑ Yes E No 405 406 <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> BP West Coast Products LLC 503) 524-6191 <br /> MAILING OR STREET ADDRESS 409 <br /> PO BOX 6038 <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> ARTESIA CA 90702-6038 <br /> PROPERTY OWNER TYPE E 1.CORPORATION ❑2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3. PARTNERSHIP [:15.COUNTY AGENCY ❑7. FEDERAL AGENCY 413 <br /> 11L TANK OWNER,INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> BP West Coast Products LLC (503) 524-6191 <br /> MAILING OR STREET ADDRESS 416 <br /> PO BOX 6038 <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> ARTESIA CA 90702-6038 <br /> TANK OWNER TYPE E 1.CORPORATION ❑2. 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- 1 4 1 1 14 16 1 5 1 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED ❑4.SURETY BOND [:17.STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE [:15. LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> E 3. INSURANCE E16. EXEMPTION E19.STATE FUND&CD 422 <br /> VI.LEGAL NOTIFICATION AND MAILINGADDRESS <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 information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATUBE OF APPLICANT DATE 424 PHONE 425 <br /> (503) 524-6191 <br /> NAmt OF APPL NT(print) 426 TITLE OF APPLICANT 427 <br /> RUTH HA Environmental Compliance Specialist <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br />