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L)f2 <br /> ..r UNIFIED PROGRAM(UP)FORM <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> one Daoe per site Page of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION O 7.PERMANENTLY CLOSED SITE <br /> (Check one hem only) ❑2.INTERIM PERMIT ❑4.AMENDED PERMIT ❑&TEMPORARY SITE CLOSURE ❑ S.TANK REMOVED 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sam as FACRry NAME or DaA) 3 FACILITY ID# <br /> Tesoro West Coast Company,LLC USA,CC#68150 }- %! _ 1 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE U 4.LOCAL AGENCY/DISTRICT <br /> 13975 E HWY 88 LOKEFORD, CA 95237 ® 1.CORPORATION [15.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION 3. FARM El 5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE [12.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 ❑ 3.PARTNERSHIP ❑7. FEDERAL AGENCY' 4102 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or -If owner or UST Is a public agency:name of supervisor of division,section or <br /> REMAINING AT SITE trustlands? office which operates the UST(This Is to contact person for the tank records.) <br /> 3 404 ❑ Yes ® No as <br /> 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 40e <br /> Tesoro Sierra Properties, LLC 253-896-8700 <br /> MAILING OR STREET ADDRESS eos <br /> 3450 South 3W Way, Suite no. 201 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Aubum I WA 98001-5931 <br /> PROPERTY OWNER TYPE 0 1.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.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 41e 1 ZIP CODE 419 <br /> TANK OWNER TYPE 1.CORPORATION 2. INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420 <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY [17. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K HO 44- 5 i& I G 1-2-1 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 ❑S.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> [13. 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 kTal notifications and mailing. 423 <br /> Lege) notifications and mailings will be sem to the tank owner unless box 1 or 21s checked. ❑ 1.FACILITY ®2. PROPERTY OWNER ❑3.TANK OWNER <br /> VII. APPLICANT SIGNATURE <br /> Certification-I oenlly that to%M A tion provided herein is we and acctAate to the best of my knowledge. <br /> SIGNATURE OF P DATE:423-07 424 H E 425 <br /> -846 S}coo <br /> NAME OF AP - 426 TITLE OF APPLICANT:General manager retail services 427 <br /> OFFICIAL USE ONLY DATE RECEIVED CUPA PA DISTRICT/INSPECTOR <br /> STATE UST FACILITY NUMBER 428 1998 UPGRADE CERTIFICATE NUMBER <br /> UP FORM(1/2000 Version) 1 Formerly SWRCB Form A <br /> SBC UST-A.doc <br />