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I 'ICn DOn! DAAA r nklCnr rnATCn CnDe' <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACIL'1TY <br /> (one page per site) Page 1 of <br /> ak- <br /> TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ILS.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE R 0.1-11 3 c'� 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FA2rwME DN <br /> r stress As) FACILITYIG/ <br /> Arco Facility#0434 � � � Z ` 1 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE 0 4.LOCAL GENCYIDISTRICT' <br /> S. Hutchins St PK 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION Lj 3.FARM 05. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE [12-DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY` 4o2 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section a office <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 0 404 ❑ Yes X No 405 405 <br /> It. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 4oe <br /> Arco Products Company <br /> MAILING OR STREET ADDRESS 409 <br /> 4 Centerpointe Drive <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> La Palma CA 90623-1066 <br /> PROPERTY OWNER TYPE 1.CORPORATION 2. INDIVIDUAL Lj 4.LOCAL AGENCY!DISTRICT ❑6.STATE AGENCY <br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7. FEDERAL AGENCY 413 <br /> III.TAM(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 416 ZIP CODE 419 <br /> La Palma CA 90623-1066 <br /> TANK OWNER TYPE 1.CORPORATION 2. INDIVIDUAL ❑4. LOCAL AGENCY!DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3. PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY T Ca (91 6) 322- if au s arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE 1.SELFINSURED El 4.SURETY BOND 0 7.STATE FUND <br /> ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE ❑5. LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3. 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 jk3.TANK 423 <br /> OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify,that the information provided herein is We and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 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 local--only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use Dory) 429 <br />