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JP= 4i WO& <br /> UNI D PROGRAM CONSOLIDATED F�M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of <br /> TYPE OF ACTION ❑j.NEW SITE PERMIT [yJ3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION(Specify change- ❑7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT local use only) <br /> ❑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# 1 <br /> Tosco Corporation#255417/5417/30877 HIM I I HITT <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE <br /> ® 1. CORPORATION ❑ 4. LOCAL AGENCY/DISTRICT'5. COUNTY AGENCY' <br /> 760 �' ❑2. INDIVIDUAL ❑ <br /> BUSINESS TYPE ®1 GAS STATION ❑ 3.FARM [:15.COMMERCIAL ❑ 3. PARTNERSHIP ❑ 6. STATE AGENCY' <br /> [_]2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER ❑ 7 FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or `If 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 ®No 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Tosco Corporation 1 (510) 277-2319 <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 /> Tosco Corporation 1 (925)277-2319 <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 /> TY(TK)HQ 4 F41 - p 3161214141 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 /> Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1. FACILITY 1:1 2. PROPERTY OWNER ® 3. TANK OWNER 423 <br /> Legal not cations and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> v 4` (602) 728-7201 <br /> NAME OF APPLICANT(print) TITLE OF APPLICANT 426 <br /> Allison Asaro Licensing Representative <br /> F11) oo 37,�G tlA�47�' <br /> STATE UST FACILITY NUMBER(For local use only) 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 428 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />