Laserfiche WebLink
'IAIICICn OOnCO Ake nnKlcnI rn ATcn CnnAA <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Pageof y <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ ZPERMANENTLY CLOSED SITE <br /> (Check ane item only) ❑4.AMENDED PERMIT specify change local use only ® 8.TANK REMOVED <br /> ❑67EMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same a.FACILITY NAME or oeA-WN Business A4) 3 FACILITY IDK <br /> 1 <br /> Arco#434 501 W. Kettleman Ln Lodi <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE Lj 4.LOCAL GENCY/DISTRICT' <br /> S. Hutchins St N 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS N 1.GAS STATION Ej 3.FARM D 5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OFTANKS Is facility on Indian Reservation or 'g owner of UST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the UST(This Is the contact person for the tank records.) <br /> 0 404 ❑ Yes N No 405 406 <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40T PHONE 408 <br /> Arco Products Company <br /> MAILING OR STREET ADDRESS 409 <br /> 4 Centerpointe Drive <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> La Palma CA 90623-1066 <br /> PROPERTY OWNER TYPE 1.CORPORATION Cl 2.INDIVIDUAL Lj 4. LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7. FEDERAL AGENCY 413 <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Arco Products Company 714-670.5300 <br /> MAILING OR STREET ADDRESS 416 <br /> 4 Genterpointe Drive <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> La Palma I CA 90623-1066 <br /> TANK OWNER TYPE N 1.CORPORATION ❑2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5. COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE-ACCOUNT_ NUMBER <br /> TY (TK) HO Call (916) 32 -9669 if auedons arise <br /> 4z, <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE 1.SELF-INSURED U4.SURETY BOND 7.STATE FUND <br /> ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE [15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> a' V1. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notitications and mailing. <br /> I notifications and mailings will be sent to the tank owner unless box 1 or 2 is Checked. ❑ 1.FACILITY ® 2. PROPERTY OWNER [13.TANK OWNER 423 <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify tnot the information provided herein is tae and accurate to the best of my knowledge. <br /> SIG URE OF APPLI DATE 424 PHONE 4' <br /> 7/19/02 209-2342450 <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 use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local ase only) 429 <br />