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sow <br /> UNIFIED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUND STORAGE TANK <br /> E -OPERATING PERMIT APPLICATION -FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT Z 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACIL C U aoo. <br /> (Check one irern only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. <br /> FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Tesoro/She1168151 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 35 N. Cherokee Lane Lodi <br /> 403. aos. <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes Z 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4°7. PHONE 408, <br /> Tesoro Sierra Properties, LLC Mail Stop: TX!-022 210 626-6681 <br /> MAILING ADDRESS aos. <br /> 19100 Ridgewood Parkway <br /> CITY 410. STATE 411. 1 ZIP CODE 412 <br /> San Antonio TX 78259 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> Tesoro West Coast Company, LLC Mail Stop: TX1-022 (210) 626-6681 <br /> 428-3, <br /> MAILING ADDRESS <br /> 19100 Rid ewood Parkwa <br /> CITY 428-4. STATE 428-s. ZIP CODE azs-6. <br /> San Antonio TX 78259 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> Tesoro West Coast Company, LLC Mail Stop: TX1-022 (210) 626-6681 <br /> 416, <br /> MAILING ADDRESS <br /> 19100 Ridgewood Parkway <br /> CITY <br /> 417. STATE 418. ZIP CODE 419, <br /> San Antonio TX 78259 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> [1 7.FEDERAL AGENCY Z 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 4 1 5 16 16 1 2 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> 423. <br /> Issue permit and send legal notifications and mailings to: E] 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> Z 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 certi that the informs ' ovi is ue accurate and in full compliance with le al requirements. <br /> Ap>;LICANT SIGNAT E DATE 424 PHONE azs. <br /> c ' )1/7/11 6 %7- �B`tS <br /> APPLICANT NA E(print) j 426 <br /> APPLICANT TITLE 4z� <br /> V Environmental Compliance <br /> Administrator <br /> �ffn nu 2L� <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org � <br /> N 101 sI 1 z <br />