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e <br /> AFIED PROGRAM CONSOLIDATED FOI. <br /> UNDERGROUND STORAGE TANK , ff <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 aoo. <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# _ _ , / rte, 1. <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as FACIMY 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 /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408. <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> MAILING ADDRESS 409. <br /> P.O. BOX 6038 <br /> CITY 410• STATE 411. ZIP CODE 412. <br /> ARTESIA CA 90702 <br /> 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 STATE 428-5 ZIP CODE 428-6 <br /> 7CA <br /> STOCKTON 95207 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME <br /> ala. PHONE 415• <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> MAILING ADDRESS 416. <br /> P.O. BOX 6038 <br /> CTTy 417, 1 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 ACCOUNTNUMBER <br /> TY(TK)HQ 44- 10 141 1 T-4-T-6-1-5 I 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 /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify thate I ormation rovided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424• 1 PHONE 425. <br /> xx/"tf 7/ J 714-670-3958 <br /> APPLICANT NAME(print) 426• APPLICANT TITLE 427 <br /> BRATZO BASAGOITIA Environmental Compliance Specialist <br /> UPCF UST-A Rev.(12/2007) <br />