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UN*IED PROGRAM CONSOLIDATED IF i0N V*C <br /> TANKS va'A30(oa' <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) 1065 <br /> Page _ of _ <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION(Specify change- ❑7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT local use only) ❑8.TANK REMOVED 400 <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# I1 <br /> ConocoPhillips Company#255417 <br /> BUSINESS SITE ADDRESS 401 FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT- <br /> 1700 EAST YOSEMITE AVE ® 1. CORPORATION ❑ 5. COUNTYAGENCY- <br /> ❑2. INDIVIDUAL ❑ 6. STATE AGENCY' <br /> BUSINESS TYPE ®1.GAS STATION ❑ 3.FARM ❑5.COMMERCIAL ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 <br /> ❑2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'H owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE trustlands? division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 2 404 ❑Yes ®No405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> ConocoPhillips Company 1 (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 ZIP CODE 419 <br /> Phoenix AZ 85072 <br /> TANK OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 420 <br /> ® 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> IM RnARnOEI=QlIAI17ATIONII-qISTC)RACiE-EJF.EACCCIIININIIMRFR <br /> TY(TK)HQ 4 4 1 - 101411 998 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) ❑ 1 SELF-INSURED ❑'4. SURETY BOND ❑ 7. STATE FUND ❑' 10. LOCAL GOV=T 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 /> ±el <br /> e box to indicate which address should be used for legal notifications and mailing. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK OWNER 423 <br /> fications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> C ification: 1 cert' tha the information provided herein is true and accurate to the best of my knowledge. <br /> SI NAT OF ILI ANT DATE PHONE 425 <br /> 12/04/02 424 1 (602) 728-4970 <br /> NAME OF APPL CANT(print) TITLE OF APPLICANT 426 <br /> Pam Ruesga Compliance Specialist <br /> STATE UST FACILITY NUMBER(For local use only) 427 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 428 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />