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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION— FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1 NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE °09 <br /> !Check nM nem mhV ❑ 3 RENEWAL PERMIT <br /> ❑ b.TEMPORARY FACILITY CLOSURE ❑ y.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY °00 FACILITY ID k _ i. <br /> 3 (Agency L e Onfy/ <br /> BUSINESS NAME(Some as Facdiry Name or DBA—Doing Buriness As) <br /> Tesoro/USA 68150 <br /> BUSINESS SITE ADDRESS 103 CITY 1a <br /> 13975 E. Hiway 88 Lockeford <br /> FACILITY TYPE ® L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 101 Is the facility located on Indian Reservation m 105 <br /> ❑ 3.FARM El 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4nr PHONE 4oe <br /> Tesoro Sierra Properties, LLC 253 896-8700 <br /> MAILING ADDRESS +9 <br /> 3450 South 344" Wa , Suite 201 <br /> CITY 41. .STATE 411 <br /> ZIP CODE 412 <br /> Aubum I WA ---- - --- - <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4ze-1 PHONE 4zi2. <br /> Tesoro West Coast Company, LLC (253)896-8700 <br /> MAILING ADDRESS cea <br /> 3450 South 344th Way, Suite 201 <br /> CITY 4284 STATE 4z 5. <br /> ZIP CODE 42e-6 <br /> Aubum WA 98001 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Tesoro West Coast Company, LLC (253)896-8700 <br /> MAILING ADDRESS <br /> ns <br /> 3450 South 344th Way, Suite 201 <br /> CITY 417 STATE 41& ZIP CODE 419 <br /> Aubum WA 98001 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4zo <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- O 4 5 6 6 2 Call the State Board of Equali>ation,Fuel Tax Division,if there are questions. 411 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue Permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR 411 <br /> ® 3 TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 4os. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certifv that the information provided herein it true accurate and in full compliance with 1 1 re uirementa. <br /> PLICA <br /> TSI RE DATE a4. PHONE 4zs <br /> s 6/8/2009 559 585-8156 <br /> APPLICANT AME(print) 4z4 APpLLCANT TITLE 421 <br /> Sand E wards Environmental Com liance Administrator <br /> UPCF UST-A Rev,(1712007)•IR www.unidocs.org <br />