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UNIFIED PROGRAM CONSOLIDATED FORMr <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑1.NEW PERMIT [13.RENEWAL PERMIT ®5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE Mo. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change)Name Change ❑S.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(S.as FACILITY NAME.,DBA-Doing Business As) 3, FACILITY <br /> ARCO Facility No.06335 ID# <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 402. <br /> Arch ®I.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ®1.GAS STATION [13.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [12.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP [17.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency: name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408. <br /> BP West Coast Products LLC 714 670-5402 <br /> MAILING OR STREET ADDRESS 409. <br /> P.O.Box 6038 <br /> CITY 410. STATE 411 ZIP CODE 412, <br /> Artesia CA 90702-6038 <br /> PROPERTY OWNER TYPE ® I.CORPORATION ❑2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 411 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> BP West Coast Products LLC (714)670-5402 <br /> MAILING OR STREET ADDRESS 416. <br /> P.O.Box 6038 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Artesia CA 90702-6038 <br /> TANK OWNER TYPE 1.CORPORATION Lj 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) Z 1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> [:12.GUARANTEE [15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER [199.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the took owner unless box I or 2 is checked. ❑ 1.FACILITY [12. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is no and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424. PHONE 425. <br /> C�/� -'r A%Awrvs,- 12/27/01 (714)670-5402 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427 <br /> Carlos Rodriguez Environmental Compliance Specialist <br /> STATE UST FACILITY NUMBER(Agency ve4 only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF hwf2730(1/99)-32/37 http://www.unidocs.org Rev.04/17/00 <br />