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FROM J. Schetter PHONE NO. : 5306667692 Dec. 02 2005 02:43PM P2 <br /> O FIED PROGRAM CONSOLIDATED FORITi <br /> TANKS EkTs;,a <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑3 RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANEN'I'I.Y 1'l.()Srn SITF. 400. <br /> (Clack vnu item only) L)4,AMENDED PERMIT (Specify change)Name Change ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION <br /> f BUSINESS NAME(SfiM as FACILITY NAME nr DBA-Doing Business Az) :{ FAC'ILITY <br /> --7 I <br /> ARCO Facifi No. 00595 ID9 1. <br /> NEAREST CROSS STREET tot. FACILITY OWNER TYPE 4.I.,(.)CAL AGENCY/DISTRICT" 402. <br /> Hlghwa 99 ® 1.CORPORATION ❑S.COUNTY AGENCY• <br /> RUSTNESS 1.GAS STATION 3.hAPI,4 5.COMMERCIAL 401 ❑2. INDIVIDUAL, ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTI LER ❑3.PARTNERS111? ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404 Is facility ou Indian Reservation 403. 'If owaer of UST is a public agency: came of.upeTvisoz of division,section or 406. <br /> RPMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person t(x the tank records.) <br /> 3 ©Yes ®No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PliONE 409. <br /> BP West Coast Products LLC 800 525-5857 x6233 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. Box 6038 <br /> CITY STATE 411 ZIP CODE ail. <br /> alo. <br /> Artesia CA 90702-6038 <br /> PROPERTY OWNER TYPF. M 1.CORPORATION 0 2.INDIVIDUAI. ❑4,LOCAL AGENCY/DISTRICT T 6.STATE AGENCY 413. <br /> ❑3.PAJZTNFRS14IP ❑5.COUNTY AGENCY ❑ 7.FEDERAL ADEN(-Y <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONY 415. <br /> BP West Coast Products LLC (800)525-5857 x6233 <br /> MAILING OR STRP„FT ADDRESS ale. <br /> P.O.Box 6038 <br /> CITY 417, STATE 41s. 21P CODE 419. <br /> Artesia I CA 90702-6038 <br /> TANK OWNER TYPE I.CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRTCT 6.STATE AGENCY a20 <br /> ❑3.PARTNFRSHJ.P ❑S.COUNTY AGENCY E]7.FEDERAL AGENCY <br /> 1V.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 4 1 1 1 4 1 6 1 5 1 Call(916)322-9669 if uestions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) 0 L SELF-INSURk:D 0 4,SURE'T'Y BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM J22 <br /> ❑2.GIJARANTI5I3 ❑5.LF,TTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE ❑6.SXeMPI'R)N ❑9.STATE FUND&CD <br /> VL LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address slw.dd Ie uscJ for tnwal notifications and mailing. <br /> Legal notifications and mailings will be sant to the tank owner unless box I or 2 is checked ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification' I certify that the intbrmaboo provided It"ciu is true and aoc.,�tn to the lm%t of my knowledge. <br /> SIrNATUI OF PLICAN ( DATE 47A, PHONL• 425 <br /> .{I 12/02/2005 (800)525-5857 x6233 <br /> NAME OFAPPLICANT(print) 120 TITLE OF APPLICANT 427, <br /> John Sclidter Company Rep. <br /> STATE UST FACILITY NUMBER(Agency vac only) 423 1998 UPGRADE CERTIFICATE NUMBER(,agency sae only) 129. <br /> (See Data Element 1,abtyve_ <br /> UPCF Hwfwrc-a(1/99)-1/7 http://www.unidocs.org Rcv.N116/110 <br />