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UNIF1ED PROGRAM CONSOLIDATED MORN - 4 <br /> I)NDERGR(IUND STORACIr'rANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> 100.limn wr Ijow.%) <br /> I'VPI:OFACTIO ® 1 NF'4VPI::RMIh ❑ (1IANGfiO(''NPORNIA"PION ❑ 7 PLRh(:1NLN'I"F•AC•Il-I('YCLOSURE: 4' <br /> #CtcrA rn,e 11cm Nil%1 NF1YAL PFRMUI' <br /> --_ ❑ 3 Rf <br /> _-_•.._...._...._.._—..,_.-„ ❑ /' TFMI OR.tiltl'FAC:IL1'_fV C'LOfilNtl:: ❑ V 1'RANBfrR PERM1•Il"I" <br /> --- <br /> I. FACILITY INFORMATION <br /> �•.1"O'fAL NUM(iGR Of US Is—Al f•1CIL19 Y 40+ _.'INE.SSNAiU h'IC(c.K qK rIPu TV n aau n,1104-noinq w—asAs)2 (keen <br /> IL)!1>� LLJ <br /> _-T�" <br /> .f-. <br /> , <br /> ARCO#06080 <br /> IIIFSIN£SS S11 k ADDRESS —^-- — 101. CITY' <br /> 85 East Louise Avenue _ Lao <br /> q)r <br /> -- - - - <br /> F ACILl1"Y TYPr ® 1 MOTOR VEHICLE FUELING +oi Indian <br /> Re__...-._— r <br /> ❑ 2.FUEL,I)tSTRIHIl1•lON If the facility Iocnled on Indianservauen or <br /> PROMS(7R ❑ O OI HER I frust Wids? ❑Yes No 1 <br /> II. PROPERTY OWNER INFORMATION <br /> PROVIiXFYOWNER NAME PHONE 429 <br /> BP West Coast Products LLC _ (714)670-3928 <br /> MtAILINOA DRESS <br /> P.O.Box 6038 <br /> STAT- tl 11PC0- <br /> Artesia CA , 90703-6038 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPFRAI OR NAME n 423.4 MONI i2 3 <br /> Jamal Kabariti _ _ (209)983-9144 <br /> MRfF NG ADDR:-VSS r._ _-__. _...... ____._� 4233 <br /> 85 East Louise Avenue <br /> +s-a <br /> S fA asa•s IP Col.F 4206 <br /> Lathrop CA _ 95330 <br /> IV. TANK OWNER INFORMATION <br /> I ANK OWWA NAME — at+ PRONE 413 <br /> BP West Coast Products LLC (7l4)670-392& T <br /> __—_ __ <br /> MAIL-TNG ADDRESSata <br /> P.O.Box 6039 <br /> CIT Y — 417 STATE 413 7.IP CODT <br /> Artesia CA 90702-6038 _ <br /> OWNER TYPE ❑ 4,LOCAL.AGENCYIDISTRICT ❑ S.COUNTY AGENCY ❑ 6,STATE ACI NCY <br /> ❑ 7.FFDFRAI AGP..NC'Y M 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMRFR <br /> TY(TK)HV 44- 0 1 1 4.=1 4� 6 5 Cali the State Hoard of Equaliration.Fuel Tax Division,if there are questions sz1 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal miticattons and mailings to: ❑ 1.FACILITY OWNER "j <br /> ❑ 4.TANK OPERATOR <br /> (] 3,TANK OWNER ❑ 5.FALL-IT'Y OP[RArOR <br /> SUPERVISOR OF DIVISION,SECTION.OR OFFICE(Requirad For hiblie Agencies Only) <br /> Vii.APPLICANT SIGNATURE <br /> C'EK�1'IFIC;ATiUN: 1 certifythat the information provided herein is true,accurate,and in full Compliance with le al re uirements. <br /> APPt.ICAN'F SIGNATURE PHONF +1s <br /> _ :•�� �— 10/12/2010 <br /> APPLICANTNAMF: riot} "i,6' (714 670-3958 <br /> (P APPLICANT'TITLE <br /> R.C.Ciossetty Environm"tal Compliance S etialist <br /> VPCM UST-A Rev.(12/2007) <br />