Laserfiche WebLink
F <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® I.NEW PERMIT JiL5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check are item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACIL''"Y 40a. FACILITY ID# <br /> 3 (Agency Use Only) fj <br /> BUSINESS NAME(Same as Facility- .,me or DBA-Doing Business As) 3. <br /> ARCO #06080 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 85 East Louise Avenue <br /> FACILITY TYPE Z 1.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? ❑ 1.Yes ❑ 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40 . PHONE 408, <br /> BP West Coast Proaucts LLC (714) 670-3928 <br /> MAILING ADDRESS 409, <br /> P.O.Box 6038 <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Artesia CA 90702-6038 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> Jamal Kabariti (209) 983-9144 <br /> MAILING ADDRESS 428-3. <br /> 85 East Louise Avenue <br /> CITY 4284. STATE 428-5. ZIP CODE 428-6. <br /> Lathrop CA 95330 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> BP West Coast Products LLC (714) 670-3928 <br /> MAILING ADDRESS 416. <br /> P.O.Box 6038 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> CA 90702-6038 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 014 114 6 5 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 <br /> VI. PERMIT HOLDER INFORMATION' <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <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: 1 certify that the' o alloq providedall herein is trueaccurate and in full cornliance with le al requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> 10/12/2010 714 670-3958 <br /> APPLICANT NAME(print) 426• APPLICANT TITLE 427 <br /> R.C. Gossett Environmental Compliance Specialist <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />