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UNIFIED PROGRAM CONSOLIDATED FORM ✓ ) <br /> UNDERGROUND STORAGE TANK1 t31v <br /> OPERATING PERMIT APPLICATION-FACILITY INFTION [[ <br /> (One form per facility) <br /> 64�TYPE OF ACTION ❑ 1.NEW PERMIT Rd5.CHANGE OF INFORMATION El7.PERMANENT FACILITY CLOSURE 400" <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> TOTAL NUMBER OFUSTs AT FACILITY 404. FACILITY ID# /, .3 1 <br /> a (Agency Use Only) C30V0 D <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business.As) 3. <br /> S :�'s s aJ S�- <br /> BVSINES§SITE ADDRESS � _ 103 CITY ^ � � tom• <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING 2.FUEL DISTRIBUTION 403' Is the facility located on Indi Reservation or 405. <br /> Ll 3.FARM C14.PROCESSOR El6.OTHER Trust lands? E]Yes KNo <br /> PROPERTY OWNER NAME �7" PHONE 4�• <br /> (�S3 � 6- 314 <br /> MAILING ADDRESS Tesoro Sierra Properties, LLC 409. <br /> 3450 South 344th Way, Suite 201 <br /> CITY Auburn, WA 98001-5931 ZIP CODE 412. <br /> TANK OPERATOR NAME 428-1 PHONE 42&2 <br /> Tesoro West Coast Company, LLC �P 3�f 428.3 <br /> MAILING ADDRESS 3450 So. 344th Way, Suite 201 <br /> CITY Auburn, WA 98001-5931 28-5 ZIP CODE 428.6 <br /> TANK OWNER NAME 414. PHONE 415. <br /> Tesoro West Coast Company, LLC 0L 416. <br /> 3450 MAILING ADDRESS 3450 So. 344th Way, Suite 201 <br /> CITY Auburn, WA 98001-5931zIP coDE 419. <br /> OWNER TYPE: Cl 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> C1 7.FEDERAL AGENCY V1.NON-GOVERNMENT <br /> TY(TK)HQ 44- 0 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 /> V3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> CERTIFICATION: I certify that the information provided herein is true,accurate and in full compliance with legal requirements. <br /> APPLICANT SIGN TURE , DATE 424• PHONE 425. <br /> Midi as s tv <br /> APP " ANT NAME(print) Manager Environmental&Budge TITLE 422 <br /> UPCF UST-A Rev.(12/2007) <br />