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UNIFIED PROGRAM CONSOLIDATED F <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_of <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change)Name Change ❑8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. 1 FACILITY <br /> ID# L <br /> ARCO Facility No.0595 <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> Hammer/HWY 99 ® 1.CORPORATION [:15.COUNTY AGENCY* <br /> BUSINESS ®1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403 ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.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 /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Madeline Scannavino <br /> MAILING OR STREET ADDRESS 409. <br /> 5463 Cherokee <br /> CITY 410. STATE ZIP CODE 412. <br /> Stockton CA 95205 <br /> PROPERTY OWNER TYPE ❑1.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 4w PHONE 415. <br /> BP West Coast Products LLC 714-670-5402 <br /> MAILING OR STREET ADDRESS 416. <br /> P.O.Box 6038 <br /> CITY 417. STATE 418. ZIP CODE 4M <br /> Artesia CA 90702-6038 <br /> TANK OWNER TYPE ® 1.CORPORATION [12.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 1 1 1 1 1 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOV'T MECHANISM 422 <br /> [12.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <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 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424, 1 PHONE 425. <br /> / yC se'WA'efflW':P'- 12/27/01 714-670-5402 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Carlos Rodriguez 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 hwf2730(1/99)-4/37 http://www.unidocs.org Rev.04/17/00 <br />