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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 ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USI's AT FACILITY 01 FACILITY ID# t. <br /> 3 (Agency Use Onh) <br /> BUSINESS NAME(Sums as FACILITY NAME or DBA-Duing Business As) 3. <br /> ARCO 06080 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 85 E.LOUISE AVE LATHROP <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? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 1117 PHONE 408. <br /> BP WEST COAST PRODUCTS LLC 714-670-3928 <br /> MAILING ADDRESS 409. <br /> PO BOX 6038 <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> ARTESIA CA 90702 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429 1 PHONE 428 2 <br /> JAMIL KABARITI 209-983-9144 <br /> MAILING ADDRESS 428.3 <br /> 85 E.LOUISE AVENUE <br /> CITY 428 4 STATE 428-5 ZIP CODE 428-6 <br /> LATHROP ICA 95330 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 77T-FH 11 TNF 415 <br /> BP WEST COAST PRODUCTS LLC 714-670-3928 <br /> MAILING ADDRESS a16. <br /> COMPLIANCE DEPARTMENT,PO BOX 6038 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> ARTESIA CA 90702 <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- 1 U 1 4 1 1 1 4 1 6 1 5 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 4.1. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ L 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) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com liance with le al requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425 <br /> 714-670-3928, <br /> APPLICANT NAME(print) 426. APPLICANT ITLE 4'7 <br /> RICHARD GOSSETT ENVIRONMENTAL COMPLIANCE SPEC 1A1,1S F <br /> Arco 06080,Belshire Environmental Services <br />