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i� b <br /> UNIFIED PROGRAM(UP)FORM we L[ <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> one pace per site Facts of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) [12.INTERIM PERMIT ❑4.AMENDED PERMIT ❑&TEMPORARY SITE CLOSURE ❑ 8.TANK REMOVED 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or Di 3 FACILITY IDM <br /> Tesoro West Coast Company,LLC USA,CCM68222 F /� <br /> /`1 L <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE U 4.LOCAL AGENCY/DISTRICT <br /> 2132 MARIPOSA RD STOCKTON, CA 95205 ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 0 1.GAS STATION 0 3. FARM 5. COMMERCIAL ❑ 2. INDIVIDUAL [16.STATE AGENCY' <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER d03 ❑ 3.PARTNERSHIP [17.FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency name of supervisor of division,section or <br /> REMAINING AT SITE trustlands7 office which operates the UST(This is the contact person for the tank records.) <br /> 4 404 ❑ Yes 9 No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 406 <br /> Tesoro Sierra Properties, LLC 253-896-8700 <br /> MAILING OR STREET ADDRESS 406 <br /> 3450 South Wh Way, Suite no. 201 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Auburn WA 98001-5931 <br /> PROPERTY OWNER TYPE 1.CORPORATION El 2.INDIVIDUAL LJ 4.LOCAL AGENCY/DISTRICT 06.STATEAGENCY <br /> ❑ 3.PARTNERSHIP [15.COUNTY AGENCY ❑7. FEDERAL AGENCY 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Same as property owner <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE 1.CORPORATION 02ANDIVIDUAL 4. LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420 <br /> ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑7. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K HQ 44 L{ G I_-2-I Call 916 322-9669 ff questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE <br /> METHOD(s) ® 1.SELF-INSURED ❑4. SURETY BOND ❑7.STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br /> ®2. GUARANTEE ❑ 5. LETTER OF CREDIT [18. STATE FUND&CFO LETTER ❑ 99. OTHER: <br /> ❑ 3. INSURANCE ❑ 6. EXEMPTION ❑9. STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. a23 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER <br /> VII. APPLICANT SIGNATURE <br /> Certification-I certify that the info abon provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APP DATE:4-23-07 424 PHONE 6 425 <br /> NAME OF AP 426 TITLE OF APPLICANT:General manager retail services 42 <br /> OFFICIAL USE ONLY DATE RECEIVED CUPA PA DISTRICT/INSPECTOR <br /> STATE UST FACILITY NUMBER 428 1998 UPGRADE CERTIFICATE NUMBER 429 <br /> UP FORM(1/2000 Version) 1 Formerly SWRCB Form A <br /> SBC UST-A.doc <br />