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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® L NEW PERMIT ❑ 5.CHANGE OF INFORMATION El7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only-) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> 4— <br /> -L-FACILITYi[NFRvIATION <br /> TOTAL NUMBER OF USTs AT FACILITY ao4. FACILITY ID H '`t' <br /> 3 (Agency Use Only) F A — 0 0 0 — 0 0 0 <br /> BUSINESS NAME(Same a FACILUY NAME or DBA-Doing Business As) 3. <br /> Tesoro West Coast Company, LLC USA#68150 <br /> BUSINESS SITE ADDRESS 103 CITY 144 <br /> 13975 e. Hwy 88 Lockeford, Ca. 95237 <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 /> H. PROPERTY OWNER INFORMATI0IY <br /> PROPERTY OWNER NAME 407, PHONE 408 <br /> Tesoro Sierra Properties 210-626-6225 <br /> MAILING ADDRESS 40' <br /> 19100 Ridgewood Parkway <br /> CITYOto STATE, all ZIP CODE ate. <br /> San Antonio TX 78259 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429-1 PHONE 428.2 <br /> Tesoro West Coast Co., LLC 210-626-6225 <br /> MAILING ADDRESS 429'8 <br /> 19100 Ridgewood Parkway <br /> CITY 4284 STATE 429-5 ZIP CODE 428-6 <br /> San Antonio TX 78259 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Same as property owner ( ) <br /> MAILING ADDRESS 416, <br /> CITY 41 STATE 418 ZIP CODE 419 <br /> OWNER TYPE: ❑ 4_LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 410 <br /> ❑ 7.FEDERAL.AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> ------------ <br /> TY(TK)HQ 44- 0 1 4 1 5 16 16 1 2 1 Call the Stalc Board of Equalization,Fuel Tax Division,if there are questions. 421 <br /> BVI.PERMIT HOLDER INFORMATION � <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION. I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> PRI.ICAN S1GNA RE DATE 424 PHONE: 425 <br /> 1 2-23-12 559-585-8156 <br /> APPLICANT N E(print) 426 APPLICANT TITLE.: 427 <br /> Sandy Edwards Environmental Compliance Administrator <br /> t;PCF UST-A Rev.(1212007) t a <br />