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IFIED PROGRAM CONSOLIDATED FC' A, <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_j Of <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400 <br /> (Checl one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.TANK REMOVED <br /> [3 6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACuxrY NAME or DBA-Doing Business As) 3. FACILITY <br /> ARCO Facility No.00595 ID# 3 O <br /> NEA-MST CROSS STREET 401, FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 402. <br /> Harmmer/HWY 99 ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUS]NESS 1.GAS STATION 3.FARM ❑5.COMMERCIAL 403• El2.INDIVIDUAL El 6.STATE AGENCY* <br /> TYP L ❑2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. 'If owner of UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 408. <br /> Madeline Scannavmo <br /> MAILING OR STREET ADDRESS 409. <br /> 5463 Cherokee <br /> CITY 410. STATE 411• 1 ZIP CODE 412. <br /> Stockton I CA 95205 <br /> PROPERTY OWNER TYPE D 1.CORPORATION ®2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> BP West Coast Products LLC 714-670-5311 <br /> MAILING OR STREET ADDRESS 416• <br /> 4 Centerpointe Dr. <br /> CITY 417. 1 STATE 418, ZIP CODE 419. <br /> La Palma CA 90623 <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT 0 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(TK)HQ 44- Call(916)322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) N 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.INSURANCE [16.EXEMPTION [19.STATE FUND&CD <br /> f <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 4'- <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATUP OF APP T DATE 424. 1 PHONE 425. <br /> 2/21/2003 800-525-5857 x6233 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> John Schetter Environmental Compliance Specialist <br /> STATE UST FACILITY NUMBER(Agency use only) 428• 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />