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TIED PROGRAM CONSOLIDATED FI Ce ,fes TANKS UNDERGROUND STORAGE TANKS - FACILITY �9 J (One page per site) Page_of TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATIONCLOSED SITE 400. (Check one item only) ❑4.AMENDED PERMIT (Specify change)Name Change 8. D' ❑6.TEMPORARY SITE CLOSURE I. FACII,ITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3, FACILITY �J 1 ARCO FacilityNo. 06080 ID! 3 IPA Fi!, 1 NEAREST CROSS STREET 1�6r 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. Interstate 5 ® 1.CORPORATION ❑5.COUNTY AGENCY* BUSINESS ® 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403• [12.INDIVIDUAL ❑6.STATE AGENCY* TYPE [:12.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* 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. REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) 3 ❑Yes ONO II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. BP West Coast Products LLC 800 525-5857 x6233 MAILING OR STREET ADDRESS 409. P.O.Box 6038 CITY 410. STATE 411. ZIP CODE 412. Artesia CA 90702-6038 PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY M. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. BP West Coast Products LLC (800)525-5857 x6233 MAILING OR STREET ADDRESS 416. P.O.Box 6038 CITY 417. 1 STATE 418. ZIP CODE 419. Artesia CA 90702-6038 TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 0 1 4 1 1 1 4 1 6 1 5 1 Call 916 322-9669 if questions arise 421. V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 [12.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER [199.OTHER: ❑3.INSURANCE [16.EXEMPTION [19.STATE FUND&CD VI. LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. 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. VII. APPLICANT SIGNATURE Certificat' certify that the information provided herein is true and accurate to the best of my knowledge. SIG TU OF APPLIC NT DATE 424. 1 PHONE 425. Ci 04/12/04 (800)525-5857 x6233 NAM APPLICA T(print) - 426. TITLE OF APPLICANT 427. Omar Vasquez Company Rep. STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. (See Data Element 1,above. UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00