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�y <br /> L..WFIED PROGRAM CONSOLIDATED FORL r <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION— FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT Z 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE °00 <br /> iChrr4.vre aero m+iy3 ❑ 3.RENEWAL PERMIT <br /> ❑ b.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY °0° FACILITY ID k t. <br /> - - 3 (Agency use only) — — S' <br /> ESS NAME(Same u l$V Name or DBA–[)0019 MWIness As) <br /> Tesoro/Shell 68150 <br /> BUSINESS SITE ADDRESS 103 CITY w <br /> way 8 Lockeford <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION °01 Is the facility located on Indian Reservation or as <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ b.OTHER Tnut lands? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTYOWNER NA ME +0> PHONE +w <br /> Tesoro Sierra Properties, LLC 210 626-6681 <br /> MAILING ADDRESS +as <br /> MS:TX1-022, 19100 Ridgewood Parkway <br /> CITY +10 <br /> STATE +11 ZIP CODE 412 <br /> San Antonio TX 78259 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 421-1 PHONE +2e-2 <br /> Tesoro West Coast Company, LLC (21 n) 626-6681 <br /> MAILING <br /> ADDRESS---4284 <br /> MS:TX1-022, 19100 Ridgewood Parkway <br /> CITY +2a. <br /> STATE +''-s's ZIP CODE +zse. <br /> San Antonio I TX 78259 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME +,+ PHONE 413 <br /> Tesoro West Coast Company, LLC (210) 626-6681 <br /> MAILING ADDRESS ale <br /> MS:TX1-022, 19100 Ridgewood Parkwa <br /> CITY nrSTATE 413 PCODE +w <br /> San Antonio ZITX 18259 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY <br /> ❑ b.STATE AGENCY +m <br /> ❑ 7.FEDERAL AGENCY ® s-NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 1415 6 6 2 Call[he State Board of Equalization,Fuel Tax Division,if there are questions. i21 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agemws Only) 4W <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that the information provided herein is true accurate and in full compliance with 1 air uirements. <br /> LICANT SIG URE VAIE °+ s PHONE + <br /> d� 12/1/2010 559 585-8156 <br /> APPLICANT tFAME(print) 4ze. APPLICANT TITLE +n <br /> Sandy Edwards Environmental Compliance Administrator <br /> UP('F UST-A Rev.(12/2007)-I/2 www.anfdoes.org � <br />