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r <br /> UNIFIED PROGRAM CONSOLIDATED FORM rc / ;N'3 <br /> UNDERGROUNDSTORAGETANKOPERATING PERMIT APPLICATION-FACILITY INF ATIper facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILI400' <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as FACadrY NAME or DBA-Doing Business As) 3. <br /> (aS S 10 15 <br /> BUSINESS SITE ADDRESS 103. CITY 19. <br /> t,,( L - - - Z 2 <br /> FACILITY TYPE ❑ 1.MOTOR VEHICLE FUELING 2.FUEL DISTRIBUTION 403' Is the facility located on India Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes �No <br /> 1101 11 <br /> PROPERTY OWNER NAME 407. PHONE 409. <br /> MAILING ADDRESS Tesoro Sierra Properties, LLC 5� SIT 6 <br /> 4°9. <br /> 3450 South 344th Way, Suite 201 <br /> CITY Auburn, WA 98001-5931 ZIP CODE 412. <br /> TI�7LOPEI2ATORI�iTORN�ATION�" <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> Tesoro West Coast Company, LLC (°' 3�f <br /> MAILING ADDRESS 3450 So. 344th Way, Suite 201 42&3 <br /> CITY Auburn, WA 98001-5931 28-5 ZIP CODE 428.6 <br /> l <br /> IV. <br /> TANK`OWNER,IlV'FORMATT aN _ ` 1 <br /> TANK OWNER NAME r _ Y 414. "PHONE h 415. <br /> MAILING ADDRESS Tesoro West Coast Company, LLCM $ 3 416. <br /> 3450 So. 344th Way, Suite 201 <br /> CITY Auburn, WA 98001-5931 ZIP CODE 419. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY V4.NON-GOVERNMENT <br /> TY(TK)HQ 44- 0141Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> 11� Sill;11 <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER <br /> ❑ 4.TANK OPERATOR 423 <br /> 3K3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal re uirements. <br /> APPLICANT SIGN TURE DATE424. PHONE 425. <br /> Jxkidl g as s ggj <br /> APP ANT NAME(print) Manager EnAume b&Budy 24 T TITLE 427 <br /> UPCF UST-A Rev.(1212007) <br />