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FIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404, FACILITY ID# _ _ L <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) 3, <br /> ARCO #06080 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 85 E. LOUISE AVE LATHROP <br /> FACILITY TYPE ® 1.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, PHONE 408. <br /> BP WEST COAST PRODUCTS LLC 714-670-3928 <br /> MAILING ADDRESS 409. <br /> P.O. BOX 6038 <br /> CITY 410, STATE 411. ZIP CODE 412. <br /> ARTESIA CA 90702 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 428-2 <br /> JAMIL KABARITI 209-983-9144 <br /> MAILING ADDRESS 428-3 <br /> 85 E. LOUISE AVENUE <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> LATHROP CA 95330 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> COMPLIANCE DEPARTMENT 714-670-3928 <br /> MAILING ADDRESS 416. <br /> BP WEST COAST PRODUCTS LLC, P.O. BOX 6038 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> ARTESIA CA 90702 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 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- C4111 4 6 5 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 com fiance with le al requirements. <br /> AP LICANT SIGNATURE DATE 424. PHONE 425. <br /> 714-670-3928 <br /> APPtLI ANT N E rint) 426. APPLICANT TITLE 427 <br /> JENNIFER M .MARINAS Environmental Compliance Specialist <br /> 5LOqLAa <br /> UPCF UST-A Rev.(12/2007) <br />