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t <br /> 1 <br /> UNIFIED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUND STORAGE TANK "Ir a3�g�i i <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION ��I <br /> (011C 1*1 <br /> IYI'L OF ACTION ® I NEW PI-'RMIT CHANGE OF INFORMATION ❑ 7. PERMANENT FAC'fLrrY CLOSURE <br /> (Check One iten,o'lltil 3 RENEWAL PER".IIT6,'I-EMPORARYFAC'ILI'fYC•LOSt1RL <br /> ❑ ❑ ❑ ).TRANSFEP.PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs Al'FACILITY 404 I FACILITY ID fi <br /> 2 (.-I gent•Use Onl,) <br /> BUSINESS NAME(Same as rAC1t.1T)'N,A\1C or DDA-Doing auitness As) <br /> ARCO#06080 <br /> BUSINESS SITE ADDRESS 1033. CITY 104 <br /> 85 East Louise Avenue Latlhro <br /> FACILITY TYPE Z 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? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 1 PHONE 409 <br /> BP West Coast Products LLC _ (714)670-3928 <br /> MAILING ADDRESS 409 <br /> P.O. Box 6038 <br /> CITY 110 STATE alt ZIP CODE W <br /> Artesia CA 1 90702-6038 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 1 PHONE 428-'- <br /> Jamal Kabariti 209)983-9144 <br /> MAILING ADDRESS 428-3 <br /> 85 Fast Louise Avenue <br /> CITY 418-4 STATE 428-5 1 ZIP CODE 428-6 <br /> Lathrop CA 95330 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 4i•l PHONE 415 <br /> BP West Coast Products LLC (714)670-3928 <br /> MAILING ADDRESS 416 <br /> P.O.Box 6038 <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> Artesia CA 90702-6038 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 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- 1 0 1 4 1 1 1 4 1 6 1 5 Call the Statc Board of Equalization,Fuel Tax Division,if there are questions °1 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> nor, <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <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 1 PHONE 425 <br /> 10/12/2010 714 670-3958 <br /> APPLICANT NAME(print) 42a APPLICANT TITLE 427 <br /> R.C. Gossett Environmental Compliance Specialist <br /> ('PCF t1Sf-A Rev.(12/20117) <br />