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ArTED PROGRAM CONSOLIDATED F <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page 1 of 1 <br /> TYPE OF ACTION ❑1.NEW PERMIT [13.RENEWAL PERMIT ®5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) [14.AMENDED PERMIT (Specify change) [18.TANK REMOVED <br /> [16.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAr or DBA-Doing Business As) 3. FACILITY <br /> ARCO Facility No. 9600 »ia <br /> NEAREST CROSS STREET 401, FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> Harding ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR [-14.PROCESSOR [16.OTHER ❑3.PARTNERSHIP [-17.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404 I5 facility on Indian Reservation 405. -If owner of UST is a public agency: name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes ®No <br /> IT. PROPERTY OWNER INFORMATION' <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Atlantic Richfield Company 714-670-5423 <br /> MAILING OR STREET ADDRESS 409. <br /> P.O. Box 6038 <br /> CITY 410, STATE 411. ZIP CODE 412, <br /> Artesia CA 90702-6038 <br /> PROPERTY OWNER TYPE 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> M.TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415, <br /> Atlantic Richfield Company 714-670.6425 5-y 02 <br /> - <br /> MAILING OR STREET ADDRESS 416. <br /> P.O. Box 6038 <br /> CITY 417, STATE 418. ZIP CODE 419. <br /> Artesia CA 90702-6038 <br /> TANK OWNER TYPE ® L CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> [13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 0 1 0 1 5 1 0 1 6 Call(916)322-9669 if questions arise 421. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED [14.SURETY BOND [17.STATE FUND [110.LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE [15.LETTER OF CREDIT [IS.STATE FOND&CFO LETTER [199.OTHER: <br /> ❑3.INSURANCE [16.EXEMPTION [19.STATE FUND&CD <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 [12. PROPERTY OWNER 0 3.TANK OWNER 421 <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certi t the information provide in is true and accurate to the best of my knowledge. <br /> SIGN REO P ICANT DATE 424PHONE 425. <br /> 5/7/2001 714-670442r'&VO Z <br /> NAMrOF APPLICANT(prin <br /> 426. TITLE OF APPLICANT 427. <br /> Carlos L. Rodriguez Environmental Compliance Contractor <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NU MBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF hwfwre-b(1/99)-1/4 http://www.unidoo.org L/Y.. ctvC/�OyyJURReev.02/16/00 <br />