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ur4 MED PROGRAM CONSOLIDATED FORm <br /> UNDERGROUND STORAGE TANK " <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> E <br /> TYPE OF ACTION ❑ 1.NEW PERMIT IN <br /> 5.CHANGE OF FORMATION El 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) E] 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE E] 9.TRANSFER PERMITis <br /> Te:w <br /> F <br /> onmkho <br /> 1 7 <br /> TOTAL NUMBER OF USTs.AT FACILITY <br /> 401* FACILITY ID# <br /> (Agency <br /> Use <br /> Only) <br /> 3 <br /> BUSINESS NAME(same as FACILITY RAI ffi or DBA-Doing Business As) 3. <br /> ARCO 02133 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 2908 BENJAMIN HOLT DR STOCKTON - <br /> 403. 405, <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING El 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM [1 4.PROCESSOR ❑ 6.OTHER Trust lands? El Yes ®No <br /> IL TION <br /> PRO ww .P 1, ...OR1%IA <br /> A. <br /> 407. PHONE 409, <br /> PROPERTY OWNER NAME <br /> BP WEST COAST PRODUCTS LLC 714-670-3928 <br /> 409. <br /> MAILING ADDRESS <br /> P.O. BOX 6038 411. ZIP CODE 412. <br /> CITY <br /> 4�Ts TATE <br /> ARTESIA ICA 90702 <br /> 11'A Op <br /> w <br /> EW09 INFO <br /> TANK OPERATORNAME 428-1. PHONE 423-2 <br /> LAWRENCE WIGHT (209) 478-5552 <br /> 428.3 <br /> MAILING ADDRESS <br /> 2908 BENJAMIN HOLT DR <br /> CITY 428-4 STATE 428.5 ZIP CODE 429-6 <br /> STOCKTON ICA 95207 <br /> lvA <br /> A <br /> e. <br /> TANK OWNER NAME 414. PHONE 415. <br /> COMPLIANCE DEPARTMENT 714-670-3928 <br /> 416. <br /> MAILING ADDRESS <br /> BP WEST COAST PRODUCTS LLC, P.O. BOX 6038 <br /> CITY an. 1 STATE 418. ZIP CODE 419. <br /> ARTESIA CA 90702 - <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT E] 5.COUNTY AGENCY [1 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY 0 8.NON-GOVERNMENT <br /> -777777r77777 <br /> w VBOARD:.0P,EQ44"-n10 <br /> X. T-$ FIEK <br /> ACCOUNTI�ta <br /> - - <br /> 421. <br /> TY(TK)HQ 44- 041 465 Call the State Board of Equalization,Fuel Tax Division,if there are questions.111111 1 <br /> _ VI PERMIT HO�,1?ER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 3.TANK OWNER 0 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> 77777=- <br /> 7. <br /> CERTIFICATION: I certify that the information provided herein is t ue,accurate,and in full compliance with legal requiremefitsi") <br /> APPLICANT SIGN RE DATE 1124. 1 PHONE 425. <br /> 1714-670-3928Ti J <br /> APP 4�IC <br /> _)b NT NAMKLp print) 426. APPLICANT TITLE 427 <br /> NIFER M. MARINAS Environmental Compliance Specialist <br /> UPCF UST-A Rev.(12/2007) <br /> 13 <br />