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yOURCes <br /> Z <br /> STATE OF CALIFORNIA ?" " .`I <br /> STATE WATER RESOURCES CONTROL BOARD a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A a� At <br /> C�(Inpry N`� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 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 FACP 6100 Dery j . Anse]. <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 25775 South Patterson Pass Hwy 5'L'0 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> 'Tracy CA 95376 209-635-7777 <br /> ✓ Box <br /> TOINDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY (]-FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Ej* 1 GAS STATION 2 DISTRIBUTOR / IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 0 3 FARM 4 PROCESSOR 5 OTHER OR TRUST LANDS 1. r 1: (1 t r C -•Q A 4 2 <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 /> _I , i� WITH AREA CODE <br /> (z7" i c 2t�a-�•3�-1777 Arco Maintenance <br /> NIG TS: NAM LAST, IRST H WI AREA CODE NIGHTS: NAME(LAST,FIRST) 800-272-6349 <br /> Arco fain enance 806-T13-g�49 Arco Maintenance <br /> PHONE#WITH AREA COQF <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 to indicate INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 17 315 Studebaker Rd. CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 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 ✓ box to indicate INDIVIDUAL LOCAL-AGENCY <br /> �z–, � STATE-AGENCY <br /> 17315 Studebaker Rd. CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Cerritos I 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 10 16 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE E:j 4 SURETY BOND <br /> D 5 LETTER OF CREDIT =6 EXEMPTION 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.❑ it.❑ 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 8 SIGNATURIA I APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> Daniel B. Goalwin - Consultant B.C.E. Inc 2/1/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <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: Barghausen. `'onsulting Engineers Inc . ; <br /> 4612 Roseville Rd. , rth Highlands , CA 95660 <br /> 18215 72nd Ave . South , Kent , WA 98032 <br />