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'esoun <br /> STATE OF CALIFORNIA `i <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FO'F(II�"i�' 1 T9 t. . "v; <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE ENV1D•-�'•F' G ! - <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SRE <br /> ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ a TEMPORARY SITE CLOSURE ©� <br /> I. FACILRYISITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ARCO FACf434 Edward D Sequeira <br /> ADDRESS NEARESTCROSSSTREET PARCEL#(OPrONAQ <br /> 501 West Kettleman Lane Hutchins <br /> CITU NAME - STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Lodi CA 95240 209-333-0141 <br /> I/ BOX <br /> TO INDICATE CORPORATION [M INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY Q COUNTYAGENCY (]STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> 2 DISTRIBUTOR ❑ ✓RESERVATION J#OF TANKS AT SITE E.P.A. I.D.#(aWknal) <br /> TYPE OF BUSINESS � ) GAS STATION <br /> RESERVATION y/ <br /> Q 3 FARM O 4 PROCESSOR Q S OTHER OR TRUST LANDS 1K 3 CAL 000 025 862 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRS 0 PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 800-272-6349 <br /> Se ueira, Ed 209-333-0141 Arco Maintenance <br /> NIG T ' M LAST FIRS H WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 800-272-6399 <br /> c flint T ce 80(5-�211L-6349 Arco Maintenance <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAMECARE OF ADDRESS INFORMATION <br /> At <br /> Richfield Company Environmental Health & Safety De t. <br /> MAf jYCy fSker STREET <br /> ADDRESS <br /> ,y✓1 b bl = INDIVIDUAL 0 LOCAL-AGENCY 0 STATE AGENCY <br /> '' // j t Rd. Pt CORPORA71ON Q PARTNERSHIP 0 COUNTY-AGENCY 0 FEDEMLAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Cerritos CA 90701 310-407-2605 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED <br /> NAME OF OW NER CARE OF ADDRESS INFORMATION <br /> Arco Products Company Environmental Health & Safety Dept. <br /> MAILING OR STREET ADDRESS ✓ box b Micas# (] INDIVIDUAL Q LOCAL-AGENCY E-1 STATE AGENCY <br /> 17315 Studebaker Rd. ICi CORPORATION 0 PARTNERSHIP 0 COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE 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 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box b Wkau id T SELF INSURED O 2 GUARANTEE El 5 INSURANCE 0 4 SURETY BONG <br /> O 5 LETTEROFCREDIT O 5 EXEMPTION = N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or 11 is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ 111.Xj <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED 8 SIGNATU APPLICANTS TITLE DATE MONTWDAYNEAR <br /> Daniel B. GoalWjn ) - Consultant B.C.E.Inc 2/11/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> SI I I I I I7i �! �E6r�i div <br /> LOCATION CODE -OPTIONAL CENSUS TR�AACCTmT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL r ..�- <br /> Z ; , D� ZU L tJ <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF STE INFORMATION ONLY. <br /> FORMA(SAI) �FOflW7JA5 <br /> Preparers Barghausen C >ulting Engineers Inc. ; � <br /> 4612 Roseville Rd. , No'✓h Highlands, CA 95660 '"re <br /> 18215 72nd Ave . South, Kent, WA 98032 <br />