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U ' 'IED PROGRAM CONSOLIDATED F 'M <br /> TANKS <br /> ro�ULE D <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> 611 <br /> e T Ii(e) 1065If. <br /> TYPE OF ACTION ®1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION(Specify change- ❑7• po' Ei fP C L(Check one Rem only) ®4.gMENDED PERMIT local use ordy) ❑8. V I lr'L S <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# <br /> ConocoPhillips Company#255886 `® z <br /> BUSINESS SITE ADDRESS 401 FACILITY OWNER TYPE 4. LOCAL <br /> 2701 W MARCH LN 1. CORPORATION g 5. COUNTYAT" <br /> AGENCY•ISTRIC <br /> 2 INDIVIDUAL ❑ 6. STATE AGENCY" <br /> BUSINESS TYPE ®1.GAS STATION ❑ 3.FARM ❑5.COMMERCIAL 3. PARTNERSHIP <br /> 02.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER <br /> ❑ 7. FEDERAL AGENCY" 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or .ti owner of UST is a public agency:name of supwvr"of <br /> REMAINING AT SITE Inrstiands? division,section or office which operates the UST. <br /> (Th the contact persm for the tank records.) <br /> 3 .404 ❑Yes ®Noaos <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> ConocoPhillips Company (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---rZFMDE 419 <br /> Phoenix AZ 85072 <br /> TANK OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY l DISTRICT ❑ 6. STATE AGENCY 420 <br /> ® 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 1 0 1191 <br /> 9 9 8 8 Call(916)322-9669 if questions arise 421 <br /> P <br /> INDICATE METHOD(S) 1.SELF-INSURED 4. SURETY BOND 7.$TATE FUND <br /> 3. ❑ 10. LOCAL GOV=T MEC:HANI5M <br /> 2. GUARANTEE 5. LETTER OF CREDIT 8. STATE FUND&CFO LETTER ❑99. OTHER: <br /> ❑ 6. EXEMPTION 9. STATE FUND&CO 4 <br /> 22 <br /> Check one box to indicate which address should be used for legal notifications and=. 1. FACILITY 2. PROPERTY OWNER ® 3.TANK OWNER 423 <br /> Legal notifications and mailings will be sent to Me tank owner unless box 1 or 2 is check. <br /> Certification: I cartify that the information provided herein Is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> (925)277-2404 <br /> [NAME OF APPLICANT(print) TITLE OF APPLICANT 426 <br /> Janette Thompson Regional Compliance Specialist <br /> STATE UST FACILITY NUMBER(Forlocal use ordy) 427 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 428 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />