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P�SoUR es C <br /> STATE OF CALIFORNIA k ° <br /> STATE WATER RESOURCES CONTROL BOARDM. Y R. <br /> Q� o <br /> 61, <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION �jF{ ,. .1.A i e ' <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE PLri M l in <br /> �/ Y l ` <br /> MARK ONLY D 1 NEW PERMIT 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ARCO FAC#.' 6100 Donald J. Ansel <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 25775 South Patterson Pass Hwy 580 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Tracy CA 95376 209-835-7777 <br /> ✓ BOX <br /> TO INDICATE O CORPORATION INDIVIDUAL [�D PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ,/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> EINRESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS 4 CAL 000 039 442 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 800-272-6349 <br /> Ansel, David 209-835-7777 Arco Maintenance <br /> NIG TS: NAM LAST,FIRST) H WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 800-272-6349 <br /> Gdo aintenance 806-5"I -6349 Arco Maintenance <br /> PHONE#WITH AR A CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Atlantic Richfield Company Environmental Health & Safety Dept. <br /> MAILING OR STREET ADDRESS ✓ box toindicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 17315 Studebaker Rd. EKI CORPORATION I] PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <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 OWNER CARE OF ADDRESS INFORMATION <br /> Arco Products Company Environmental Health & Safety Dept. <br /> MAILING OR STREET ADDRESS 11y�✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 17315 Studebaker Rd. K]CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 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 10 10 15 0 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> D 5 LETTER OF CREDIT [7] 6 EXEMPTION 0 99 OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.[__� III. <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&SIGNATUR ) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> Daniel B. Goal%4in - Consultant B.C.E.Inc 2/1/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br /> Preparer: Barghauser -onsulting Engineers Inc . ; <br /> 4612 Roseville Rd. , _ ,rth Highlands , CA 95660 <br /> 18215 72rd Ave. South , Kent , WA 98032 <br />