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dr <br />Ar— <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION — FACILITY INFORMATION <br />(One form per facility) <br />❑ I. NEW PERMIT ®5. CHANGE OF INFORMATION ❑ 7. PERMANENT EnciLITY CLOSURE <br />I Y111 ()I ACT ION1. <br />Whe, A r,rr, uen? "MI ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9_ TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />—TITOTAL <br />-F�4/` <br />NUMBER OF USTs AT FACILITY AP' <br />FACILITY ID <br />_ <br />_ <br />` <br />3 <br />(Agency Use On/10 <br />O <br />BUSINESS NAME (Same as f iciliq• Nante or DBA - Doing Business AS) <br />Tesoro/Shell 68151 <br />BUSINESS SITE. ADDRESS 103 <br />CITY 104 <br />35 N. Cherokee Lane <br />Lodi <br />FACILITY TYPE ID I MOTOR VF i1CLE FUELING ❑ 2. FUEL DISTRIBI(TION 403 <br />Is the facility located on Indian Reservation or 40_ <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />I rust lands'.' ❑ 1. Yes ® 2. No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME <br />PHONE 408 <br />Tesoro Sierra Properties, LLC Mail Stop: TX1-022 <br />(210 626-6681 <br />ao1+ <br />MAII ING ADDRFSS <br />19100 Ridgewood Parkway <br />CITY 410 STATE 411 ZIP CODE 412 <br />San AntonioTX 78259 <br />1 1 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 429-1 <br />PHONE 428-2 <br />Tesoro West Coast Company, LLC Mail Stop: TX1-022 <br />1(210) 626-6681 <br />MAILING ADDRESS I <br />19100 Ridgewood Parkway <br />CITY 4'-9 4 <br />STATE428 ` <br />ZIP CODE az8 a <br />San Antonio <br />TX <br />78259 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE', 415 <br />Tesoro West Coast Company, LLC Mail Stop:.TX1-022 <br />(210) 626-6681 <br />416 <br />MAILING ADDRESS <br />19100 Ridgewood Parkway <br />417 <br />CITY <br />STATE. 418 <br />ZIP CODE 419 <br />San Antonio ITX <br />78259 <br />OWNER TYPE ❑ 4 l OCAL AGENCYIDIS I"RICr ❑ 5. COUNTY AGENCY ❑ 6. STA -1-17 AGENCY 420 <br />❑ 7. FEDERAL AGENCY ® 8. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 1014151616121 Call the State Board of Equalization, Fuel `fav Division, if there are questions. 411 <br />VI. PERMIT HOLDER INFORMATION <br />aa3 <br />Issue permit and send legal notifications and mailings to: ❑ 1. FACILITY OWNER ❑ 4. TANK OPERATOR <br />® 3. TANK OWNER ❑ 5 FACILITY OPERATOR <br />SUPERVISOR OF DIVISION. SECTION, OR OFFICE (Required for Public Agencies Only) 408 <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the information provided herein is true, accurate, and in full compliance with legal requirements. <br />�RN(CANTIGNAT REi <br />DATE 424 <br />PHONE: 42` <br />1,-0-�As <br />8/26/2011 <br />(559) 585-8156 <br />,� <br />APPICANT NA F (prim) 4'-8 <br />L <br />APPLICANT TITLE 41' <br />Sandy Edwards <br />Environmental Compliance Administrator <br />I'PCF I.'ST-A Rev. (12/2007) - 1/2 www.unidocs.org Alk� I pfc� <br />jr comppimiad <br />