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UNTIED PROGRAM CONSOLIDATED F M <br /> TANKS b\-� <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) 1065 <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION(Specify change- ❑7.PERMANENTLY CLOSED SITE <br /> (Check one item only) local use onl <br /> [:]4.AMENDED PERMIT Y) ❑B.TANK REMOVED 400 <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 <br /> ConocoPhillips Company#255886 <br /> BUSINESS SITE ADDRESS 401 FACILITY OWNER TYPE <br /> 2701 W MARCH LN ® 1. CORPORATION ❑ 4. LOCAL AGENCY/DISTRICT` <br /> ❑ 5. COUNTY AGENCY' <br /> ❑2. INDIVIDUAL 6. STATE AGENCY" <br /> BUSINESS TYPE ®1.GAS STATION ❑ 3.FARM ❑5.COMMERCIAL ❑ 3. PARTNERSHIP ❑ <br /> [:]2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER ❑ 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE trustlands? division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 3 404 ❑Yes ®No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> ConocoPhillips Company 1 (925)277-2404 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. Box 52085 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Phoenix AZ 85072 <br /> PROPERTY OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 413 <br /> ❑ 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> ConocoPhillips Company 1 (925)277-2404 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O. Box 52085 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Phoenix AZ 85072 <br /> TANK OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 420 <br /> I <br /> ® 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 101411 ggg Call(916)322-9669 if questions arise 421 <br /> RITNSITI <br /> INDICATE METHOD(S) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND' ❑ 10. LOCAL GOV=T MECHANISM <br /> ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND&CFO LETTER ❑99. OTHER: <br /> ® 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK OWNER 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> C rtification. I certffy that th information provided herein is true and accurate to the best of my knowledge. <br /> S NATURE F AP LIC T DATE PHONE 425 <br /> 12/04/02 424 1 (602) 728-4970 <br /> NAfA OF APPLI (prin TITLE OF APPLICANT 426 <br /> Pam Ru sga Compliance Specialist <br /> STATE UST FACILITY NUMBER(Forlocal use only) 427 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 428 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />