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L <br /> ,tFIED PROGRAM CONSOLIDATED FGi 19 <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION 1.NEW PERMIT El 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400.1 <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE El 9.TRANSFER PERMIT <br /> ........... <br /> TOTAL NUMBER OF USTs AT FACILITY 411 <br /> FACILITY M# <br /> 3 (Agency Use Only) <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 TO_5 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> �Pi <br /> -J. <br /> PROPERTY OWNER NAME 407. PHONE 409. <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> MAILING ADDRESS 409. <br /> P.O. BOX 6038 <br /> CITY 41.0. STATE 411. ZIP CODE 412. <br /> ARTESIA CA 90702 <br /> "F1 t:" <br /> A;q FC; <br /> TANK OPERATOR NAME 428-1. PH01,M 429-2 <br /> LAWRENCE WIGHT (209) 478-5552 428A <br /> MAILING ADDRESS <br /> 2908 BENJAMIN HOLT DR <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> STOCKTON CA 195207 <br /> .0 Z; <br /> RM, <br /> ;A <br /> TANK OWNER NAME 414. PHONE 415. <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> MAILING ADDRESS 416. <br /> 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 /> ;i <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 /> 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 /> CERTIFICATION- I certify that 1 ormation provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE424, 1 PHONE 425. <br /> DATE ILa 1714-670-3958 <br /> J416 427 <br /> APPLICANT NAME(print) APPLICANT TITLE <br /> BRATZO BASAGOITIA Environmental Compliance Specialist <br /> UPCF UST-A Rev.(12/2007) <br />