Laserfiche WebLink
1 <br /> t . <br /> at- D PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY IN TION/CVS <br /> (One form per facility)E: <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 /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# _ 1 <br /> 3 (Agency Use Only) Q <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> ARCO 05450 <br /> BUSINESS SITE ADDRESS 103, CITY 104 <br /> 1617 W FREMONT STOCKTON <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> BP WEST COAST PRODUCTS LLC 714-670-3928 <br /> MAILING ADDRESS 409. <br /> P.O. BOX 6038 <br /> CITY 410_ STATE 411. ZIP CODE 412. <br /> ARTESIA CA 90702 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428x. PHONE 428-2 <br /> ALFRED B REALI (209) 462-1617 <br /> MAILING ADDRESS 428-3 <br /> 1617 W FREMONT <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> STOCKTON � CA 95203 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> COMPLIANCE DEPARTMENT 714-670-3928 <br /> MAILING ADDRESS 416. <br /> BP WEST COAST PRODUCTS LLC, P.O. BOX 6038 <br /> CITY 417. STATE 418, ZIP CODE 419. <br /> ARTESIA CA 90702 <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- 1014111416151 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> I.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 /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) " ",g <br /> vj <br /> VII.APPLICANT SIGNATURE <br /> w„ <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal re uirement <br /> PLICANT SIGNATURE DATE 424. 1 PHONE f-;= _ 425. <br /> 714-670-3928 <br /> AF(PL)CANT E(print) 426. APPLICANT TITLE 421 <br /> JrNNIFER M. MARINAS Environmental Compliance Specialist <br /> 55(o ql-1 <br /> UPCF UST-A Rev.(12/2007) <br />