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UNIFIED PROGRAM CONSOLIDATED FORM 6 / jt J t Wv <br /> UNDERGROUND STORAGE TANK sj 13 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATIO <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Cluck one nem only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> TOTAL NUMBER OF USTs AT FACB,ITY r4 . TY ID#Use OrdYJ A O � V s <br /> BUSINESS NAME(Fsmev FACn.rl'Y NAME mDa0.-Dmnaansiness As) 3. <br /> VSA S 'ST0,TtLN 4;!(A('S0 <br /> BUSINESS SITE ADDRESS 101. CITY IW. <br /> S — S'Z3=- <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING W57.FUEL DISTRIBUTION °Oz' Is the I'mility located on Indft Reservation a '05' <br /> 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes IffNe <br /> PROPERTY OWNER NAME a7. PHONE ba. <br /> MAILING ADDRESS Tesoro Sierra Properties, LLC <br /> 3450 South 344th Way, Suite 201 <br /> CITY Auburn, WA 98001-5931 / ZIP CODE 412 <br /> TANK OPERATOR NAME 4m-1 PHONE 4ze-2 <br /> MAILING ADDRESS Tesoro West Coast Company, LLC �S3 <br /> azas <br /> 3450 So. 344th Way, Suite 201 <br /> CITY Auburn, WA 98001-5931 za-s ZIP CODE 42" <br /> TANK OWNER NAME 414. PHONE 415. <br /> Tesoro West Coast Company, LLC Ste) $ - 3 <br /> MAILING ADDRFss 34So. 344th Way, Suite21 6 <br /> 550 <br /> CITY Auburn, WA 98001-5931 . zIPC.ODE 419. <br /> OWNER TYPE: [14.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY [16.STATE AGENCY 4W,❑ 7.FEDERAL AGENCY 94 NON-GOVERNMENT <br /> TY(TK)HQ 44- Call Ore State Board of Equalvation,F1rd Tax Division,if there am questions. 4zt. <br /> Issue permit and send legal notifications and mailings to. [,.,/11.FACILITY OWNER [1u <br /> 4.TANK OPERATOR 4 <br /> I1f3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> CERTIFICATION: [certify that the information provided herein is true accurate,and In full compliance with legal requirements. <br /> APPLICANT SIGN TURE ldI DATE 4M PHONE bO1 4ss_ <br /> APP ANT NAME(print) 1 Vo' O D <br /> Manager Environmental&Budget OW T TITLE +27 <br /> UPCF UST-A Rev.(1212007) <br />