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o' <br /> Ads <br /> IED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION — FACILITY INFORMATION a <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> Wheck one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID# 1 <br /> 3 1 (Agency Use On!}) — — 16�6t- <br /> ,,:,IIUSINF,SS <br /> NAME(Sameas i me or DBA-Doing Business As) 3 <br /> Tesoro/Shell 68153 �Id wewA USA C t# 0 cVA4� Tiro ll W3 <br /> BUSINESS S 103 CITY 104 <br /> 2448 W. Kettleman Lane Lodi <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4. PROCESSOR ❑ 6.OTHER Trust lands' ❑ 1. Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Tesoro Sierra Properties, LL Mail Stop: TXI-022 210) 626-6681 <br /> MAILING ADDRESS 409 <br /> 19100 Ridgewood Parkway <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> San Antonio JTX 78259 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME. 428-1 PHONE 428-2 <br /> Tesoro West Coast Company, LL ail Stop: TX1-02 (210) 626-6681 <br /> MAILINci ADDRFSS 428-3 <br /> 19100 Ridgewood Parkway <br /> CITY 4284 STATE 429-5 Z[P CODE 428-6 <br /> San Antonio TX 178259 <br /> IV. TANK OWNER INFORMATION <br /> I ANK OWNER NAME 414 PHONE 41i <br /> Tesoro West Coast Company, LLC ail Stop: TX1-022 (210) 626-6681 <br /> MAILING ADDRESS 416 <br /> 19100 Ridgewood Parkway <br /> CITY 417 1 STATE 418 ZIPCODE 419 <br /> San Antonio TX 78259 _ <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 4 5 6 6 2 Call the State Board of Equalization,Fuel Tar Division,if there are questions. 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> AcfTLICANT SIGN " URE DATE i24 PHONE42 <br /> S <br /> 1/13/2011 559) 585-8156 <br /> APPLICANT N ME(print) 426 APPLICANT TITLE 42' <br /> Sandy Edwards Environmental Compliance Administrator <br /> UPCF l ST-A Rev,(12/2007)-1/2 www.unidocs.org <br />