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f 17'L <br /> UNIFIED PROGRAM(UP)FORM &1i�/�`7 <br /> E: UNDERGROUND STORAGE TANKS - FACILITY L <br /> one page per site Pae of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑2.INTERIM PERMIT ❑4.AMENDED PERMIT ❑&TEMPORARY SITE CLOSURE ❑ 8.TANK REMOVED 400 <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA) 3 1 FACILITY ID# <br /> 1 <br /> Tesoro West Coast Company,LLC USA,CC#68152 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT <br /> 401 W KETTLEMAN LANE LODI, CA 95240 ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 0 1.GAS STATION 3.FARM 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 ❑ 3.PARTNERSHIP [17.FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency.name of supervisor of division,section or <br /> REMAINING AT SITE trustlands? office which operates the UST(This is the contact person for the tank records.) <br /> 2 ao4 ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Tesoro Sierra Properties, LLC 253-896-8700 <br /> MAILING OR STREET ADDRESS 409 <br /> 3450 South 344 'Way, Suite no.201 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Auburn WA 98001-5931 <br /> PROPERTY OWNER TYPE ED 1.CORPORATION 0 2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT Ll 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Same as property owner <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 416 ZIP CODE 419 <br /> TANK OWNER TYPE 1.CORPORATION 0 2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 42o <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE <br /> M&HOD(s) ®1.SELF-INSURED ❑4.SURETY BOND [:17.STATE FUND ❑10.LOCAL GOVT 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 /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. [31.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER a23 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify djAgrnwillon pvMjd heroin s true and accurate to the best of my knowledge. <br /> SIGNATURE � DATE:4-23-07 ata pHp - 6R Qo 425 <br /> NAME OF (print) ughes Madrid 426 TITLE OF APPLICANT:General manager retail services 427 <br /> OFFICIAL USE ONLY DATE RECEIVED CUPA PA DISTRICT/INSPECTOR <br /> STATE UST FACILITY NUMBER 428 1998 UDE CERTIFICATE NUMBER 4213PGRA <br /> UP FORM(1/2000 Version) 1 Formerly SWRCB Form A <br /> SBC UST-A.doc <br />