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` U ' VIED PROGRAM CONSOLIDATED F --M <br /> TANKS ® � <br /> UNDERGROUND STORAGE TANKS - F CILITY <br /> EE <br /> p 65 <br /> MOR <br /> of _n <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑3.RENEWAL PERMIT 05.CHANGE OF INFORMATION(Specify change- ❑7.PERMAN �r HEr1L� <br /> (Check one Item only) ❑4.AMENDED PERMIT local use only) ❑8.TANK REQ H <br /> ❑6.TEMPORARY SITE CLOSURE ����E1�VICES <br /> 1.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 <br /> ConocoPhillips Company#2611194 <br /> BUSINESS SITE ADDRESS 401 FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT- <br /> 0 1. CORPORATION <br /> 2375 TRACY BLVD 7 U- 3�(7-a ❑2. INDIVIDUAL ❑ 6. STOATS AGENCY'S <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 '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 /> 4 404 ❑Yes ®No 405 406 <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 /> 111.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 D 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 /> LTY(TK)HO 4 1 4 1 - 0 1 g g g g Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) ❑ 1. SELF-INSURED F_] 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. El 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK OWNER 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> Wil-APRLICANT SIGNATI IRE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. �'-7t 0 / <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 <br /> (925)277-2404 <br /> NAME OF APPLICANT(print) TITLE OF APPLICANT 426 <br /> Janette Thompson Regional Compliance Specialist <br /> STATE UST FACILITY NUMBER(Forlocal use only) 427 1 1998 UPGRADE CERTIFICATE NUMBER(Forlocal use only) 428 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />