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IED PROGRAM CONSOLIDATED FOW j <br /> UNDERGROUND STORAGE TANK V <br /> OPERATING PERMIT APPLICATION-FACILITY INFO ATION <br /> (One trm per facility) <br /> TYPE OF ACTION ® 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4W <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I;. FACILITY PWORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID# t' <br /> 3 (Agency Use Only) <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 /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <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 428-1. PHONE 428-2 <br /> ALFRED B REALI (209) 462-1617 <br /> MAILING ADDRESS 428-3 <br /> 1617 W FREMONT <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> STOCKTON � CA 95203 <br /> IV. 'TANK OYM W RMATm <br /> TANK OWNER NAME 414. PHONE 415. <br /> BP WEST COAST PRODUCTS LLC 714-670-3958 <br /> MAILING ADDRESS 416. <br /> 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 EQI.IALI ATION, ST STORAGE FEE ACCOUNT t4UMER <br /> TY(TK)HQ 44- 10 141 1 14161 51 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER*FORMATION <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 /> APPLICANT SWAT E <br /> CERTIFICATION: I certify that the' mation provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> �c7 714-670-3958 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> BRATZO BASAGOITIA Environmental Compliance Specialist <br /> (-/ 60 99 Z <br /> UPCF UST-A Rev.(12/2007) <br />