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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION — FACILITY INFORMATION <br /> (One form per facility) <br /> 40Q <br /> TYPE OF AC'"1-ICJN Q I.NF..4V PERMIT ® 5-CHANGE OF INFORMATION ❑ 7.PERMANENT FACILrrY CLOSURE <br /> h,>,�n.�n ,tl� ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACIE ITY CLOSURE ❑ 9."TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> -1-0FALNL'-MBER OF USTs AT FACILErY 4114 <br /> FACILITY ID _ <br /> 2 (agency Csse onlvl <br /> 13US[NESS NAME(5'ame as Facdffv Same or DBA-Doing Rusiness.1s) <br /> Tesoro/USA 68152 <br /> BUSINESS SfrF,,ADDRESSos CITY 104 <br /> 401 W. Kettleman Lane Lodi <br /> 401 405 <br /> FACILITY TYPE ® L MOTOR VEHICLE FUELING ❑ 2-FEEL[)IS`ERIBLTION Is the facility located nn Indian Reservation or <br /> ❑ FARM ❑ 4.PROCESSOR El 6.OTHER Trust lands? ❑ I. Yes ® 2 No <br /> I II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PI10NF:; 4011t <br /> I Tesoro Sierra Properties, LLC Mail Stop: TX!-022 _ (210)626-6681 <br /> 1,1AIt,ING.ADDRESS 409 <br /> 19100 Ridgewood Parkway <br /> CITY 41G STA IT: ; ZIP CODE 412 <br /> San Antonio TX f 78259 _ <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME +'=s 1 <br /> PHONE T2s-' <br /> Tesoro West Coast Company, LLC Mail Stop: TX1-022 (210) 626-6681 <br /> MAILING ADDRESS --- 429-1 <br /> 19100 Ridgewood Parkway <br /> CITY 428-4 1 STATF 328-` ZIP CODE 42" <br /> San Antonio TX 78259 <br /> ! <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME + PHONE 41i <br /> Tesoro West Coast Company, LLC Mail Stop: TX1-022 1 (210)626-6681 <br /> MAILING ADDRESS 416 <br /> 19100 Ridgewood Parkway <br /> CITY 417 STATE 413 ZIP CODE 411) <br /> San Antonio ( TX i 78259 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE-AGENCY 420. <br /> C] 7.FEDERAL AGENCY ® 3.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)FIQ 44- 1 4 5 6 6 2 j Call the State Board of Equalization,Fuel Tax Division,ifthere are questions. 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue pemnit and send legal notifications and mailings to: C1 I_FACILITY OWNER ❑ 4.TANK OPERA'r(?R 423 <br /> ® 3.TANK OWNER ❑ >.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION.SECrION,OR OFFICE(Required-for Public Agencies On[v) 406 <br /> VII. APPLICANT SIGNATURE <br /> C_E_RTIFICA"rION: I certifv that the information provided herein is true,accurate,and in full compliance with Ial re uirements€, <br /> APP �1NT S GNA ris DATE 4=`' PIlo E-. 425 <br /> J ,_. 5 3/4/2010 (55 ) 585-8156 �� � <br /> APPLICANT NAM (Print) 426 APPLICANT TrrLE -—_J 427 <br /> Sandy Edwards _ Environmental Compliance Administrator <br /> t'PCF UST-A Rev,(12/2007)-1/2 www.unidocs.org LS <br />