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_ren onnrDAAA rnelenl InATen CnC <br /> 3 evf2JANKS <br /> UNDERGROUND STORAGE TANKS - FACILI <br /> (one page per site) Page-LofL <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one hem only) ❑4.AMENDED PERMIT specify,change bral use only X8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY I SITE INFORMATION <br /> BUSINESS NAME(S..as FACILITY NAME«DBA-W uslness sM _ 3 FACILITY ID# <br /> Arco Facility#0760 X13 ro <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT• <br /> East Lodi Ave IN 1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS 14 1.GAS STATION 0 3.FARM 0 5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY` <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR❑6. OTHER 4o3 ❑ 3. PARTNERSHIP ❑7.FEDERAL AGENCY' 4o2 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of OST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trua lands? which operates the UST(This is the contact person for the tank records.) <br /> 0 404 ❑ Yes IOk No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Arco Products Company <br /> MAILING OR STREET ADDRESS 409 <br /> 4 Centerpointe Drive <br /> CITY 410 1 STATE 411 ZIP CODE <br /> 412 <br /> La Palma CA 90623-1066 <br /> PROPERTY OWNER TYPE X1.CORPORATION 2ANDIVIDUAL U 4.LOCAL AGENCY/DISTRICT 06.STATEAGENCY <br /> ❑3. PARTNERSHIP [15.COUNTY AGENCY [17. FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Arco Products Company 714.670.5300 <br /> MAILING OR STREET ADDRESS 416 <br /> 4 Centerpointe Drive <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> La Palma CA 90623-1066 <br /> TANK OWNER TYPE JS 1.CORPORATION El 2. INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 42o <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY K) HQ Call ( 1 322-9669 if auestions arse 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED [14. SURETY BOND 0 7.STATE FUND <br /> ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE [15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> [13. INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ■3.TANK 423 <br /> OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certificafion-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> 209-2342450 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Gwen Birdsong Office Mgr,K.E.Curtis Construction Co.,Inc. <br /> STATE UST FACILITY NUMBER(For boil use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br />