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STATE OF CALIFORNIA' WATER RESOURCES CONTRO"OARD FORM `A': UNDERGROUND STORAGE TANK PROGRAM SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE 10 I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION ARCO AM/PM Mini-market Bar hausen Consulting Engineers, Q.Rql a ADDRESS NEAREST CROSS STREET ✓Grr to ic.11 D PARTNERSHIP D STATE-AGENCY 0 EI CORPORATION D LIAGENCY ❑ EEGERu AGENCY S.E.C. of Hammer Lane and Holman Road FJ ❑ INDIVIDUAL ❑ cOuNn�CENcr � CITY NAME - STATE ZIP CODE SITE PHONE a,WITH AREA CODE Stockton CA 95204 N/A TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box I INDIAN EPA ID a ® I GAS STATION E] 3 FARM ❑ 5 OTHER TRUSTTMLANDS ATION N Aof HIS SI ❑ N/A AT TRIS STE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE k WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA OCOE Ng, Mitchell 213-402-1299 Conner, Charlie 213-402-1240 NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE Same 800-553-6246 Same 800-553-6246 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Atlantic Richfield Company MAILING or STREET ADDRESS 11 Box to indicate D PARTNERSHIP D STATE-AGENCY 515 South Flower Street 91 CORPORATION D LOCAL AGENCY D FEDERAL-AGENCY D INDIVIDUAL D COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE Los Angeles CA 90071 213-486-3511 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION ARCO Products Company MAILING or STREET ADDRESS ✓Be.to indicate D PARTNERSHIP D STATE-AGENCY ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY P.O. Box 5811 D INDIVIDUAL D COUNTYAGENCY CITY NAME STATEZIP CODE PHONE a,WITH AREA CODE San Mateo CA 94403 415-571-2400 IV. LEGAL NOTIFICATION AND BILLING ADDRESS -CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. ❑ III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY.AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIG DATE P. B. Tobin LOCAL AGENCY USE ONLY /^'J CO® JURISDICTION � AGENCY M M k' O V FACILITY IDof TANKS al SITE 313 CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME � PHONE N WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE L ODE CEN8U6 TM/—CT N SUPERVISOR-DISTRICT CODE BUSINESS PIAN FILED DATE FILED 3 &0 YES NO O PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTN B THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY FORM A(3-2-88) DATA PROCESSING COPY ./