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UNIFIED PROGRAM CONSOLIDATED FORM Kt / <br /> UNDERGROUND STORAGE TANK ('/4—) <br /> 4 �� <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® 1.NEW PERMIT 135.CHANGE OF INFORMATION 137.PERMANENT FACILITY CLOSURE t°4 <br /> (Cbect one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> -- <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID M F A0 0 0 0 0 0 <br /> 3 1 (Agency U-Only) <br /> BUS IN ESS NAME(Signe a FACtLM NAX6 or WA--Wr4 Business a4) } <br /> Tesoro West Coast Company, LLC USA#68150 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 13975 e. Hwy 88 Lockeford, Ca. 95237 <br /> FACILITY TYPE ® t.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 40s Is the facility located on Indian Reservation or 4os <br /> 0.3--fgm ❑ 4.PROCESSOR Q 6.OTHER Trust lands? ❑Yes ®No <br /> IL 'I IP E' TC,OWNF,RIt ORNIATi <br /> PROPERTY OWNER NAME 407 PHONE 4" <br /> Tesoro Sierra Properties 210-626-6225 <br /> MAILING ADDRESS 409 <br /> 19100 Ridgewood Parkway <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> San Antonio TX 178259 <br /> ITt. TANK t)PERlTOR iNFfI11�iA1`IN <br /> TANK OPERATOR NAME ,2S 1 PHONE 425.2 <br /> Tesoro West Coast Co., LLC 210-626-6225 <br /> MAILING ADDRESS 4n 2 <br /> 19100 Ridgewood Parkway <br /> CITY 428-4 STATE 425.5 ZIPCODE 42" <br /> San Antonio TX 78259 <br /> IV. TAS OWNER I `t1IiAATi©N <br /> TANK OWNER NAME 414 PHONE 415 <br /> Same as propeq owner ( ) <br /> MAILING ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> OWNER TYPE: ❑ 4;LOCAL ACENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ® 9,NON-GOVERNMENT <br /> `V. 11UARt1 OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44_ 0 4 5 6 2 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 431 <br /> Vh PERMIT HOLDER INFORI�rIATiQN <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 19NA' <br /> CERTIFICATION: I certify that the information provided hereia is true,accurate and in full com liance with legal requirements. <br /> �BR1IC SIGNA E DATE 424 PHONE 42s <br /> c 2-23-12 559-585-8156 <br /> APPLICANT N E(print) 42G APPLICANT TITLE 427 <br /> Sandy Edwards Environmental Compliance Administrator <br /> UPCF t ST-A Rev.(12/ZW7) <br /> u" <br /> 4is'e.Ied J�W��J� z�' <br />