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AM-NIFIED PROGRAM CONSOLIDATED FORN WIM PR#:PR0231416 FAC#:FA0003627 UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ t.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT a:^az' �' ss`a., ❑ 8.TANK REMOVED k to F-16.TEMPORARY SITE CLOSURE 400 L FACILITY/SITE INFORMATION 3425 N TRACY BLVD,TRACY BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# I PR ID# K&N FOOD&FUEL* FA0003627 PR0231416 1 NEAREST CROSS STREET FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT- TRACY 401 ® 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ® 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL [:1 2.INDIVIDUAL ❑ 6.STATE AGENCY- TYPE E] 2. 3.PARTNERSHIP E] 402 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 7.FEDERAL AGENCY* 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 office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes M No 405 MANAGER 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 BP WEST COAST PRODUCTS LLC 503 524-6191 MAILING OR STREET ADDRESS 409 PO BOX 6038 CITY ,,I STATE 4111 ZIP CODE 412 ARTESIA CA 90702-6038 PROPERTY OWNER TYPE ® I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 BP WEST COAST PRODUCERS LLC (503)524-6191 MAILING OR STREET ADDRESS 416 PO BOX 6038 CITY 417 STATE 418 ZIP CODE 419 ARTESIA I CA 90702-6038 TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 ❑3.PARTNERSHIP 115.COUNTY AGENCY ❑ 7.FEDERAL AGENCY TANK OPERATOR INFORMATION TANK OPERATOR NAME TANK OPERATOR TITLE RUTH HA ENVIRONMENTAL COMPLIANCE SPECIALIST IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-000506 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑99.OTHER ❑71 3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. X 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. LI VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 124 1 PHONE 425 (503)524-6191 NAME OF APPLICANT(print) 126 TITLE OF APPLICANT 427 RUTH HA ENVIRONMENTAL COMPLIANCE SPECIALIST STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)