Laserfiche WebLink
STATE OF CALIFORNIA _. <br /> STATE WATER RESOURCES CONTROL BOARD .��, e <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM A " <br /> COMPLETE THIS FORM FOR EACH FACILrTY/SfTE „o�,,.' <br /> MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE REM O 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> �t <br /> I. FACILfrY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ARCD AM PM Facility5569 Prestige Stations Inc, 5289 <br /> ADDRESS <br /> NEAREST CROSS STREET PARCELCOPrONAL) <br /> 3518 E. Havener Lane �CA95211 <br /> Road 092-22-28 <br /> CITY NAME SP CODE <br /> Stockton917E PHONE#WITH AREA CODE <br /> I/Box 0 209) 474-9343 <br /> T NDCAIE iZ CORPORATION D INDIVIDUAL D PARTNERSHIP D LOCAL-AGENCY D COUNIY.AOENCY• D STATE-AGENCY D FEOEML#GENCY• <br /> 'Ilowner d UST I,a pubic agowy,mmpMe tN 1 DISTRICTS' <br /> olawMlp:rarrle of Superviwr of dNbbn,cectbn,or o6ice which operate,the UST <br /> TYPE OF BUSINESS ® 1 GAS STATION Q 2 DISTRIBUTOR ✓ IF INDIAN .OF TANKS AT SITE I E.P.A, I.D.#(aptlorW) <br /> D 3 FARM O 4 PROCESSOR 0 5 OTHER OOR TRUSTRESERLATIO <br /> ANDS3 CAL 000032494 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS:NAME(LAST,FIRST) PHONE.WITH AREA CODE DAYS: NAME(UST,FIRST) PHONE.WITH AREA CODE <br /> I DLIt n <br /> Maa er 474-93 PSI Dut Mang 209 474-9343 <br /> NIGHTS: NAME(LAST,FIRST) PHONE.WITHAREACODE NIGHTS: NAME(LAST,FIRST) PHONE,WITH AREA CODE <br /> PST Maint-pnanCe (800)-553-6246 AP00 Maintenance 0 553-6246 <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION \ <br /> ARCO Products Company Environ! Health & Safet <br /> MAILING OR STREET ADDRESS �✓y Oo[blydkab D INDIVIDUAL E::] LOCAL-AGENCY D STATE-AGENCY <br /> P.O. BOx O 12 CORPORATION D PARTNERSHIP D COUNTY-AGENLY 0 FEDERALAWNCY <br /> CITY NAME STATE ZIP CODE PHONE.WITH AREA CODE <br /> Artesia CA 90702-6038 714 670-5404 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Environ. Health & Safety <br /> MAILING OR STREET ADDRESS ✓boo b irtlicaM D INDIVIDUAL D LOCAL-AGENCY D STATE.AGENCY <br /> P.O. Box 6038 EX CORPORATION D PARTNERSHIP D COUNTYAGENCY D FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE.WITH AREA CODE <br /> Artesia CA 90702-6038 (714) 670-5404 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 it questions arise. <br /> TY(TK) HQ M44- - 0 0 0 5 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY.(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓icor bh&b 1SELF-INSURED D 2 GUARANTEE 0 3 INSLIRMCE D 4 SURETY BOND <br /> D 5 LETTEROFCREOIT D 6 EXEMPTION L:j W OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the lank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 IL O III. <br /> THIS FORMHASBEEN72ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> DIME ME(PRINTED&SIGN Pr OWNERS TITLE PATE MONTHIDAYNRAR <br /> Project Architect <br /> LOCAL AGENCY USE ONLY Thomas Schoenstein - Tait & Associates <br /> COUNTY• JURISDICTION i FACILITY t <br /> m --� 131=3 <br /> LOCATION CODE-OPTIONAL CENSUS TRACT# .OPTIONAL SUPVISOR-DISTRICT CODE -CPTIONAI. <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 /> FORMA <br /> OWNER MUST FILE THIS FORN""TH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROU"^QTORAGE TANK REGULATIONS <br /> (393) <br /> Fd75W7AAT <br />