Laserfiche WebLink
, v <br /> 1 12.31 <br /> LMFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® 1.NEW PERMIT [15.CHANGE OF INFORMATION ❑ 7.PERMANENT F ITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT [16.TEMPORARY FACILITY CLOSURE E] 9.TRANSFER PEI; ECEIVEn <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404, FACILITY ID# _ _ /�,, I <br /> 4 (Agency Use Only) AIJ c tc <br /> 3. <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) OFFICE OF E <br /> ARCO 02093 MERGENCY SERVICES <br /> BUSINESS SITE ADDRESS 103, CITY 104. <br /> 3425 TRACY BLVD TRACY <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> MAILING ADDRESS 409. <br /> P.O. BOX 6038 <br /> CITY 410 STATE 411. ZIP CODE 412. <br /> ARTESIA CA 90702 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> IQBAL SING BAINS (209) 835-1605 <br /> MAILING ADDRESS 428-3 <br /> 3425 TRACY BLVD <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> TRACY CA 95376 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. 1 PHONE 415. <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> MAILING ADDRESS 416_ <br /> P.O. BOX 6038 <br /> CITY 417. STATE ats. ZIP CODE 419. <br /> ARTESIA CA 90702 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1014111416151 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: icerft)&Ptkhe information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATUR DATE 424. PHONE 425. <br /> 12/16/08 714-670-3958 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> BRATZO BASAGOITIA Environmental Compliance Specialist <br /> ARCO 02093,BELSHIRE ENVIRONMENTAL SERVICES PAGE 1 OF 5 UPCF UST-A Rev.(12/2007) <br />