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i di ozie�� <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUNDSTORAGETANK <br />OPERATING PERMIT APPLICATION — FACILITY INFORMATION <br />(One form per facility) <br />400 <br />TYPE OF ACTION ❑ I NEW PERMIT ® 5. CI IANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE <br />�(' icck tine nein onhy ❑ 3_ RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. "TRANSFER PERMIT <br />L FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 444 <br />FACILITY ID # <br />_ <br />I <br />_ <br />1 <br />3 <br />(Agency (Ise Only) <br />3 <br />BUSINESS NAME (.Same as Facility Name or DBA - Doing Business As) � <br />Tesoro/USA68151 <br />BUSINESS SITE ADDRESS 103 <br />CITY 104 <br />35 N. Cherokee Lane <br />Lodi <br />FACILITY TYPE Z 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 4033 <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 4G PHONE 409 <br />Tesoro Sierra Properties, LLC Mail Stop: TX! -022 (210) 626-6681 <br />MAILING ADDRESS 409. <br />19100 Ridgewood Parkway <br />CITY 410 <br />STATE all. 1 "LIP CODE Al2 <br />San Antonio JTX <br />478259 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428.1 <br />PI IONE 429-2 <br />Tesoro West Coast Company, LLC Mail Stogy: TX1-022 <br />(210) 626-6681 <br />MAILING ADDRESS 429'3 <br />19100 Ridgewood Parkway <br />crry 429-4 <br />STATE 428-1 <br />ZIP CODE 42" <br />San Antonio ITX <br />78259 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 PHONE 415 <br />1 <br />-Tesoro West Coast Company, LLC Mail Stop: TX1-022 I (210) 626-6681 <br />MAILING ADDRESS 416 <br />19100 Ridgewood Parkway <br />CITY 417 <br />STA FE 418 <br />ZIP CODE 419 - <br />San Antonio �TX <br />78259 <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 424 <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 'Fax 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 />Z 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required for Puhlic Agencies OnIJ) 446 <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: 1 certify that the information provided herein is true, accurate, and in full compliance with legal re uirements. <br />r LICANT SIGN TRF. <br />17 <br />DATE 424. <br />PHONE 425 <br />,(,_.,d s <br />2/8/2010 <br />559) 585-8156 <br />APPLICANT NVVME (print) 426- <br />APPLICANT TITLE 427 <br />Sandy Edwards <br />Environmental Compliance Administrator <br />UPCF IST -A Rev. (12!3007) - I/2 www.unidocs.org <br />