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IED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> F7 <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page 1 of 1 <br /> TYPE OF ACTION [11.NEW PERMIT [13.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑70QRi vlAEI�TL SED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change)Name Change ❑8.TANK O <br /> ❑6.TEMPORARY SITE CLOSURE <br /> ENVIRONMENT HEALTH <br /> I. FACILITY/SITE INFORMATION VLK101 /SERVICH <br /> BUSINESS NAME(Same as FACILM NAME or DBA-Doing Business As) 3. 1 FACILITY <br /> ARCO Facility No.0595 ID/I � 1-1 <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT' 402. <br /> Highway 99/1-lammer ® 1.CORPORATION ❑5.COUNTY AGENCY'S <br /> BUSINESS ® 1.GAS STATION 0 3.FARM 5.COMMERCIAL 403. [12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.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 N/A <br /> MAILING OR STREET ADDRESS 4W <br /> 5463 Cherokee <br /> CITY 410, STATE 41L ZIP CODE 412, <br /> Stockton I CA 95205 <br /> PROPERTY OWNER TYPE 1.CORPORATION 0 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 41; <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 (800)525-5857 x6233 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O.Box 6038 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Artesia CA 90702-6038 <br /> TANK OWNER TYPE ® 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.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 questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE ❑6.EJMMPTION ❑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 [12. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I pertify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNAOF LICANT DATE 424. PHONE 425. <br /> 1 ,, 10/12/2004 (800)525-5857 x6233 <br /> NAME OF A PLICANT(print) 426. TITLE OF APPLICANT 427. <br /> John Sche r Compliance Specialist <br /> STATE II ACILITY 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.unidoes.ot-g Rev.02/16/00 <br />