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�s°°" e <br /> STATE OF CALIFORNIA oM1 <br /> STATE WATER RESOURCES CONTROL BOARD W,"�y , o <br /> UNDERGROUND STORAGE TANK PERMIT APP "T�9�i F +L HEALT `' <br /> PERM!USERVICES °""°""r <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY 1 NEW PERMIT 0 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION [11 7 PERMANENTLY CLOSED SIE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT L] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> NAME OF OPERATOR <br /> DBA OR FACILITY NAME <br /> ARCO FAC#760 David Hildebrand <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAU <br /> 225 S. Cherokee Lane Lodi Ave <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Lodi CA 95240 209-368-7863 <br /> TO DIC TE O CORPORATION %I INDIVIDUAL O PARTNERSHIP 0 OBTNICGENCY COuKrY-AGENCY I�STATE-AGENCY = FEDERAL-AGENCY <br /> TS <br /> TYPE OF BUSINESS L GAS STATION Q 2 DISTRIBUTOR = <br /> RESERVATION <br /> IF INDDIAN #OF TANKS AT SITE E.P.A. I.D.#(a Nt 0 <br /> 3 FARM 4 PROCESSOR Q 5 OTHER OR TRUSTLANDS 4 CAL 000 009 852 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 800-272-6349 <br /> Hildebrand, David 209-368-7863 Arco Maintenance <br /> NIG HAREA CODE NIGHTS: NAME(LAST.FIRST) <br /> Tntoince 80PTY9I3Arco Maintenance 800-272-6349 <br /> PWQMF#WITH AREA COOP <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> CARE OF ADDRESS INFORMATION <br /> "Atlantic Richfield Company Environmental Health & Safety Dept. <br /> MALLI�Cf TREET ADDRESS `�boxblMkKa 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE-AGENCY <br /> 1 /J I Studebaker Rd. CORPORATION E::] PARTNERSHIP COUNTKAGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODEPHONE N WITH AREA CODE <br /> Cerritos CA 90701 310-407-2605 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Arco Products Company Environmental Health & Safety Dept. <br /> MAILING OR STREET ADDRESS boabl6Ekal4 O INDIVIDUAL 0 LOCAL AGENCY E] STATE-AGENCY <br /> 17315 Studebaker Rd. X:1 CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATEZIP COCE PHONE#WITH AREA CODE <br /> Cerritos CA 90701 310-407-2605 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 0 0 0 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box b Ntlk.l. X1 ISELF-INSURED [::]2 GUARANTEE I1 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 93 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.O II.0 III- <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(PRINTED&SIGNATU ) APPLICANTS TITLE DATE MONTHIDAY/YEAR <br /> Daniel B. Goa1Flin - Consultant B.C.E.Inc 2/11/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY x <br /> g i � ZU <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL { <br /> 2 p, I 52v <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br /> Preparer: Barghausen C sulting Engineers Inc. ; <br /> 4612 Roseville Rd. , Nk�--Lh Highlands , CA 95660 <br /> 18215 72nd Ave . South, Kent , WA 98032 <br />