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Ah ven(�L_ <br />UNIFIED PROGRAM CONSOLIDATED FORM a t a7$Jlt <br />- <br />UNDERGROUND STORAGE TANK ".6 0440 <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 />L FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 404. <br />FACILITY ID # <br />_ <br />_ <br />�� <br />/ <br />C� <br />� <br />E] <br />3 <br />(Agency Use Only) <br />/ <br />(� <br />BUSINESS NAME (Same a agility Name or DBA -Doing Business As) 3. <br />Tesoro/Shell68151 <br />ESS SITE ADDRESS 103. <br />CITY 104. <br />35 N. Cherokee Lane <br />Lodi <br />FACILITY TYPE ® 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. <br />Is the facility located on Indian Reservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />Trust lands? ❑ 1. Yes ® 2. No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />PHONE 408. <br />Tesoro Sierra Properties, LLC Mail Stop: TX! -022 <br />210 626-6681 <br />MAILING ADDRESS 409, <br />19100 Ridgewood Parkway <br />CITY 410. <br />STATE 411, <br />ZIP CODE 412, <br />San Antonio <br />TX <br />78259 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1. <br />PHONE 428-2. <br />Tesoro West Coast Company, LLC Mail Stop: TX1-022 <br />(210) 626-6681 <br />MAILING ADDRESS 428-3. <br />19100 Ridgewood Parkway <br />CITY 4284. <br />STATE 428-5 <br />ZIP CODE 428'6. <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 />MAILING ADDRESS 416. <br />19100 Ridgewood Parkway <br />CITY 417. <br />STATE 418. <br />ZIP CODE 419. <br />San Antonio JTX <br />78259 <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/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) HQ 44- 0 <br />4 5 6 6 2 Call the State Board of Equalization, Fuel Tax Division, if there are questions. 421. <br />VI. PERMIT HOLDER INFORMATION <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 />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 com liance with legal requirements. <br />LICANT SIGNAT <br />DATE 424. <br />PHONE 425. <br />(A <br />1/7/11 <br />(559)585-8156 <br />APPLICANT N E (print) 426. <br />APPLICANT TITLE 427 <br />Sandy Edwards <br />Environmental Compliance Administrator <br />UPCF UST -A Rev. (12/2007) -1/2 www.unidoes.org <br />i 2't.k1 <br />