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Ah <br />6 A-10.-� 2C' <br />omw UNIFIED PROGRAM (UP) FORM le / 0 7 Id <br />DATE RECEIVED <br />UNDERGROUND STORAGE TANKS - FACILITY <br />PA <br />one page per site Pae of <br />STATE UST FACILITY NUMBER 428 <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br />(Check one item only) ❑ 2. INTERIM PERMIT ❑ 4. AMENDED PERMIT ❑ 6.TEMPORARY SITE CLOSURE ❑ 8. TANK REMOVED <br />400 <br />I. FACILITY / SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA) 3 <br />FACILITY ID# <br />Tesoro West Coast Company, LLC USA, CC#68151 1 <br />C J <br />6 <br />NEAREST CROSS STREET 401 <br />FACILITY OWNER TYPE 4. LOCAL AGENCY/DISTRICT <br />35 N CHEROKEE LANE LODI, CA 95240 <br />® 1. CORPORATION [15. COUNTY AGENCY' <br />❑ 2. INDIVIDUAL [16. STATE AGENCY' <br />BUSINESS N 1. GAS STATION Lj 3. FARM Ej 5. COMMERCIAL <br />TYPE [:12. DISTRIBUTOR [14. PROCESSOR ❑ 6. OTHER <br />❑ 3. PARTNERSHIP [17. FEDERAL AGENCY" <br />403 <br />402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />'If owner of UST is a public agency. name of supervisor of division, section or <br />REMAINING AT SITE <br />trustlands? <br />office which operates the UST (This is the contact person for the tank records.) <br />3 4o4 <br />❑ Yes ® No 405 <br />406 <br />11. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE <br />406 <br />Tesoro Sierra Properties, LLC <br />253-896-8700 <br />MAILING OR STREET ADDRESS <br />409 <br />3450 South 344th Way, Suite no. 201 <br />CITY 410 <br />STATE 411 <br />ZIP CODE <br />412 <br />Auburn <br />WA <br />98001-5931 <br />PROPERTY OWNER TYPE 0 1. CORPORATION 0 2. INDIVIDUAL Lj 4. LOCAL AGENCY / DISTRICT 0 6. STATE AGENCY <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE <br />415 <br />Same as property owner <br />MAILING OR STREET ADDRESS <br />416 <br />CITY 417 <br />STATE 416 <br />ZIP CODE <br />419 <br />TANK OWNER TYPE 1. CORPORATION Ej 2. INDIVIDUAL 4. LOCAL AGENCY / DISTRICT 6. STATE AGENCY <br />420 <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- Call 916 322-9669 if questions arise <br />421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />`INDICATE- <br />METHOD(s) ® 1. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />® 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99.OTHER: <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD <br />422 <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and mailing. <br />423 <br />Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY ® 2. PROPERTY OWNER ❑ 3. TANK OWNER <br />VII. APPLICANT SIGNATURE <br />Certification - I certify that provided in isjue and accurate to the best of my knowledge. <br />P <br />SIGNATURE OFA:S- 0 <br />DATE: 4-23-07 424 HO E <br />s-kr96-8fio� <br />425 <br />NAME OF AP Ci hes Wadrid 426 <br />TITLE OF APPLICANT: General manager retail services <br />427 <br />OFFICIAL USE ONLY <br />DATE RECEIVED <br />COPA <br />PA <br />DISTRICT/INSPECTOR <br />STATE UST FACILITY NUMBER 428 <br />7998uPGRADE CERTIFICATE NUMBER 429 <br />UP FORM (1/2000 Version) 1 Formerly SWRCB Form A <br />SBC UST-A.doc <br />