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UNIFIED PROGRAM CONSOLIDATED FORM <br /> tt v let 6 7 TANKS <br /> ��'�1�br1 UNDERGROUND STORAGE TANKS - FACILI fY Z��� <br /> )(% Cin b UV <br /> _ of <br /> ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT 0 5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) [14.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 1 400 <br /> 1. FACILITY/SITE INFORMATION V23 t b3 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Buusine As) 3 FACILITY ID# � P � T � 10 � 0 � 1 � 0 � 5 � 1 � 2 1 <br /> ARCO 02186 C �t 1 I or 1'`� <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT* <br /> ALPINE ® 1.CORPORATION ❑ 5.COUNTY AGENCY* <br /> BUSINESS Z 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3. PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 404 ❑ Yes ® No 405 406 <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> BP West Coast Products LLC 503) 524-6191 <br /> MAILING OR STREET ADDRESS 409 <br /> PO BOX 6038 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> ARTESIA CA 90702-6038 <br /> PROPERTY OWNER TYPE ® 1. CORPORATION ❑2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑ 3.PARTNERSHIP ❑ 5. COUNTY AGENCY [:17.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 41a PHONE 415 <br /> BP West Coast Products LLC (503) 524-6191 <br /> MAILING OR STREET ADDRESS 416 <br /> PO BOX 6038 <br /> CITY 417 STATE 41e 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 [15. COUNTY AGENCY [:17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 4 1 1 14 1 6 1 5 Call 916 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED ❑4.SURETY BOND [:17.STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2. GUARANTEE ❑ 5. LETTER OF CREDIT [:18.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ®3. INSURANCE ❑6. EXEMPTION [19.STATE FUND&CD 422 <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 /> SIGNATqREjDF APPLICANT DATE 424 PHONE 425 <br /> Q q f q- (503) 524-6191 <br /> NA OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> RUTH HA Environmental Compliance Specialist <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br />