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�J <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION— FACILITY INFORMATION <br /> (One form per facility) <br /> I YPE OF ACTION ❑ I.NEW PERMIT ® 5.CHANGE OF INFORMATION <br /> (Check nue nem an/sq ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID q <br /> 3 (Agency Use Only) — <br /> BUSINESS NAME(Same as FacilityName or DBA–Doing Business As) s <br /> Tesoro/USA 68153 <br /> BUSINESS SITE ADDRESS 103 CITY 104. <br /> 2448 W. Kettleman Lane Lodi <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING403 <br /> ❑ 2.FUEL DISTRIBU"f1ON Is the facility located on Indian Reservation or 405 <br /> 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER "frust lands.) ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Tesoro Sierra Properties, LLC Mail Stop: TX!-0221 (210) 626-6681 <br /> MAILING ADDRESS 409 <br /> 19100 Ridgewood Parkway <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> San Antonio TX 178259 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 429-2. <br /> Tesoro West Coast Company, LLC Mail Stop: TX1-022 (210)626-6681 <br /> MAILING ADDRESS 428.3 <br /> 19100 Ridgewood Parkway <br /> CITY 42 STATE 4211-5 ZIP CODE 428-6— <br /> San Antonio I TX 1 78259 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415. <br /> Tesoro West Coast Company, LLC Mail Stop: TX1-022 (210)626-6681 <br /> MAILING ADDRESS 416 <br /> 19100 Ridgewood Parkway <br /> CITY 417 STATE 418 ZIP CODE 410 <br /> San Antonio I TX 78259 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 42-0 <br /> ❑ 7.FEDERAL AGENCY ® S NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 14 15 6 16 1 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 a.TANK OPERATOR 423 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with I al re uirements. <br /> AP (CANT (GNAT� DATE 424 PRONE 4't <br /> ds 5/26/2010 559 585-8156 <br /> APPLICANT NAJE(print) 426 APPLICANT TITLE 427 <br /> S ndy Edwards Environmental Compliance Administrator <br /> UPCF UST-A Rev.(12/2007)-1)2 www.unidocs.org <br />