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UNIFIED PROGRAM CONSOLIDATED FORM /�, j �! 1 ( .j t ' '6 11= UNDERGROUND STORAGE TANK C�_ �l 3 J 3 JD OPERATING PERMIT APPLICATION - FACILITY INFORMATION (One form per facility) TYPE OF ACTION ❑ 1. NEW PERMIT Ef 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 4 (Check one item only) ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT TOTAL NUM1 R OF USTs AT FACILITY 404. FACILITY ID N f� (Agency Use On(yJ 1"1 0100 4;d BUSINESS NAME (Same a FAM NAIL o, DBA -Doing Business As) S s s teN � 3. BUSINESS SITE ADDRESS 103. CITY so -),(A 104. FACILITY TYPE ❑ 1. MOTOR VEHICLE FUELING ❑ 3. FARM ❑ 4. PROCESSOR V25. FUEL DISTRIBUTION ❑ 6. OTHER 403. Is the facility located on Ind' Reservation or 405. Trust lands? ❑ Yes No PROPERTY OWNER NAME 407- 1 PHnNF 409. MAILING ADDRESS Tesoro Sierra Properties, LLC 3450 South 344th Way, Suite 201 CITY Auburn, WA 98001-5931 TANK OWNER NAME MAILING ADDRESS CITY OWNER TYPE: Tesoro West Coast Company, LLC 3450 So. 344th Way, Suite 201 Auburn, WA 98001-5931 L 414. (P-'H��ONNE`�\ 4 Tesoro West Coast Company, LLC - 3450 So. 344th Way, Suite 201 Auburn, WA 98001-5931 zIP CODE ❑ . LOCAL AGENCY/DISTRICT ❑ 5. COUNTY GENCY ❑ 6. STATE AGENCY ❑ 7. FEDERAL AGENCY (17-1. NON-GOVERNMENT TY CCK) HQ 44- (p I a I Call the State Board of Equalization, Fuel Tax Division, if there are questions. Issue permit and send legal notifications and mailings to: ❑ 1. FACILITY OWNER 993. TANK OWNER SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) ❑ 4. TANK OPERATOR ❑ 5. FACILITY OPERATOR 412. 415. CERTIFICATION: I certify that the information provided herein is true accurate and in full com lienee with legal requirements. APPLICANT SIGN TUBEDATE ata. PHONE 425. Jxkdi D. i APP ANT NAME (print) Manager EnAronmab & Budged T TITLE a2� UPCF UST -A Rev. (12/2007)