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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT IR 5.CHANGE OF INFORMATION 400 <br /> ( hed one mew may) ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> ,. L FACILITY I�O�ATION` , _ <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY IDN 1. <br /> 3 (Agency use Only) - - <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 <br /> Tesoro/Shell 68221 <br /> BUSINESS SITE ADDRESS 103 CITY 104. <br /> 2705 Country Club Dr. Stockton <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403" is the facility located on Indian Reservation or 405 <br /> 3.FARM 4.PROCESSOR Q 6.OTHER Trust lands' ❑ 1.Yes ® 2.No <br /> R O }' iFORi ATION <br /> PROPERTY OWNER NAME 407 PHONE 40& <br /> Tesoro Sierra Properties, LLC Mail Stop: TX!-022 210 626-6681 <br /> MAILING ADDRESS 4W <br /> 19100 Ridgewood Parkway <br /> CITY 410 STATE 411 ZIP CODE 412. <br /> San Antonio TX 78259 <br /> III. `A OPEItA'l<'OR U"ORMATION <br /> TANK OPERATOR NAME 429-1 1 PHONE 423.2 <br /> Tesoro West Coast Company, LLC Mail Stop* TX1-022 (210)626-6681 <br /> MAILING ADDRESS 423-3. <br /> 19100 Ridgewood Parkway <br /> CITY 42&74 STATE 428.5 ZIP CODE 42M <br /> San Antonio TX 178259 <br /> itV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 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 41z STATE 419 ZIP CODE 419 <br /> San Antonio TX 78259 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ® 8.N ON-GOVERNMENT <br /> t <br /> V. EG004 ' OIIAOE F»'E A CI'?UN'I'i fiI TNIBER <br /> TY UK)HQ 44- 10 14 1 5 16 161 2 Call the State Board ofualiaation,Fuel Tax Division, 421 <br /> Eq. on,if there are questions. <br /> Issue permit sad send legal notificatiom and railings to: ❑ 1.FACILITY OWNER423. <br /> ❑ 4.TANK OPERATOR <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION.SECTION,OR OFFICE(Requiredjor Public Agencies Only) 406 <br /> AI'I'LICA",SIONATUItE <br /> CERTIFICATION: I certify that the information provided herein is true accurate.and in full compliance wkh kzal requirements. <br /> LICANT SIGNATURE DATE 424. PHONE 425- <br /> nxjcb <br /> 1/12/2011J-.(559)585-8156 <br /> APPLICANT (print) 426 APPLICANT TITLE 427 <br /> Sandy Edwards Environmental Compliance Administrator <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />