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f <br /> L.. FIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK7 / . <br /> �.r <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATIO �• i..� <br /> (One form per fac lity) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# I' <br /> 3 (Agency Use Only) �j' �ti. 7 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3' <br /> ARCO 02133 <br /> BUSINESS SITE ADDRESS 103 CITY 104. <br /> 2908 BENJAMIN HOLT DR STOCKTON <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 /> A. 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 /> LAWRENCE WIGHT (209) 478-5552 <br /> MAILING ADDRESS 428-3 <br /> 2908 BENJAMIN HOLT DR <br /> CITY 4284 STATE 428-5 ZIP CODE 429-6 <br /> STOCKTON CA 95207 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ala. 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 USTSTORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 4 1 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) 40& <br /> NM.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal require!!! gs.' <br /> AP ICANT SIGN URE DATE 424. PHONE e azs. <br /> 714-670-3929 <br /> APPt] T NAM nnt) 426. APPLICANT TITLE 427 <br /> JENNIFER M. MARINAS Environmental Compliance Specialistr rr <br /> 3 , <br /> UPCF UST-A Rev.(12/2007) (e 6 iil <br /> �. 6kt� <br /> aka <br />