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l <br /> UNIFIED PROGRAM CONSOLIDATED FORM let <br /> x °t� <br /> UNDERGROUND STORAGE TANK l� e23; <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400, <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 0 0 FACILITY IDN F A 0 _ 0 0 <br /> 3 (agency use Only) J F <br /> 3 <br /> BUSINESS NAME(Sam n FACILITY NAME or DBA—Mir*auanm As) <br /> Tesoro West Coast Company, LLC USA#68150 <br /> BUSINESS SITE ADDRESS 103 CITY 3D4 <br /> 13975 e. 88 Lockeford, Ca. 95237 <br /> 40;, <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING [12.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME' 407 PHONE 408 <br /> Tesoro Sierra Properties 210-626-6225 <br /> 409. <br /> MAILING ADDRESS <br /> 19100 Ridgewood Parkway <br /> CITY 410 S"FATE 411_ ZIP CODE 412. <br /> San Antonio TX 78259 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4'-& PHONE 423.2 <br /> Tesoro West Coast Co., LLC 210-626-6225 <br /> J28-) <br /> MAILING ADDRESS <br /> 19100 Ridgewood Parkway <br /> CITY 428-J STATE 4'_8.5 ZIP CODE 4286 <br /> San Antonio TX 78259 <br /> � IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 4147PfE 415 <br /> Same as ro ertowner <br /> 4(b. <br /> MAILING ADDRESS <br /> CITY 417 STATE <br /> US ZIP CODE 4j9 <br /> OWNER TYPE: ❑ 4.LOCAL ACFNCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)NQ 44- 0 4 516_ 6 2 Call the State Board of Equalization,Fuel Tae Division,if there are questions. 4"h <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue pcmiit and send legal notifications and mailings to: ® I.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 4% <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE:(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> CAPRI"ICA SIGNA l RE DATE 424 PHONE" 423, <br /> 2-23-12 559-585-8156 <br /> APPLICANT N VE(print) 426 APPLICANT TITLE 427 <br /> Sandy Edwards Environmental Compliance Administrator <br /> � m ■1� <br /> UPCF US -A Rev.(12/2007) <br />