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XW UNIFIED PROGRAM (UP) FORM (( �)w <br /> UNDERGROUND STORAGE TANKS - FA�i U113ID­( lEk <br /> one page per site Pae of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑2.INTERIM PERMIT ❑4.AMENDED PERMIT ❑63EMPORARY SITE CLOSURE ❑ 8.TANK REMOVED 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA) 3 1 FACILITY ID# <br /> 1 <br /> Tesoro West Coast Company,LLC USA,CC#68153 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE 4. LOCAL AGENCY/DISTRICT <br /> 2448 W KETTLEMAN LN LODI, CA 95240 ® 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS Z 1.GAS STATION 3. FARM 5. COMMERCIAL ❑ 2. INDIVIDUAL [:16.STATE AGENCY' <br /> TYPE ❑2. DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3. PARTNERSHIP [17. 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 <br /> REMAINING AT SITE trustlands? office which operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Tesoro Sierra Properties, LLC 253-896-8700 <br /> MAILING OR STREET ADDRESS 409 <br /> 3450 South 344th Way, Suite no. 201 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Auburn WA 98001-5931 <br /> PROPERTY OWNER TYPE 1.CORPORATION El 2. INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7. FEDERAL AGENCY 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME ala PHONE 415 <br /> Same as property owner <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE 0 1.CORPORATION 2. INDIVIDUAL 0 4. LOCAL AGENCY/DISTRICT 6.STATE AGENCY ata <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> \ IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> fNDfCAT <br /> METHOD(s) ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [:110.LOCAL GOVT MECHANISM <br /> ®2.GUARANTEE ❑5. LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> E13. 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. 423 <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 <br /> VII. APPLICANT SIGNATURE <br /> Certification-I certify that the inI.954ation provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF P NTE:4-23-07 aza PHONE azs <br /> Z T-911(-. }ocs <br /> NAME OF AP i 426 TITLE OF APPLICANT:General manager retail services 427 <br /> OFFICIAL USE ONLY DATE RECEIVED COPA PA DISTRICT/INSPECTOR <br /> STATE UST FACILITY NUMBER 428 71998 UPGRADE CERTIFICATE NUMBER 429 <br /> UP FORM(1/2000 Version) 1 Formerly SWRCB Form A <br /> SBC UST-A.doc <br />