BILLING 1987 - 2002 - Laserfiche WebLink

Home Browse Search

STATE OF CALIFORNIt. WATER RESOURCES CONTROL. BOARD 6;JIpF •. Fes. FORM `A': UNDERGROUND STORAGE TANK PROGRAM W ^wm SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION', COMPLETE THIS FORM FOR EACH FACILITY/SITE Cq=1FppN P MARK ONLY ❑ 1 NEW PERMIT F-13 RENEWAL PERMIT f'"I 5 CHANGE OF INFORMATION ❑ncy CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION CARE OF ADDRESS INFORMATION Atlantic Richfield Company (ARCO) ARCO FAC No. 6100 ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY Richard D. Bokides RI CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY ADDRESS STATE NEAREST CROSS STREET -/ Box toindicale El PARTNERSHIP ElSTATE-AGENCY S. Patterson Pass Road Highway 580 �di CORPORATION ❑ LOCAL -AGENCY ElFEDERAL-AGENCY25775 ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME ❑ COUNTY -AGENCY STATE ZIP CODE STATE SITE PHONE #, WITH AREA CODE Tracy San Mateo CA 95376 ODE (209) 835-7777 TYPE OF BUSINESS: ❑ p DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # YES ❑ NO 1 GAS STATION 3 FARM ❑ ❑ 5 OTHER RESERVATION or TRUST LANDS ❑ CAC 000277769 # of TANK's AT THIS SITE LF EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE Elko DeVV &S 209 835-7777 ARCO Maintenance 415 571-2427 28 29 NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE m _ —)) 9 �)H45$ I Same 0451-9442 1 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION Atlantic Richfield Company Atlantic Richfield Company (ARCO) MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY 2000 Alameda de las Pul aS RI CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE San Mateo CA 1 944031(415)1-2 P.O. Box 5811 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION AGENCY # Atlantic Richfield Company (ARCO) Environmental Compliance Section MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY APPROVED BY NAME PHONE # WITH AREA CODE CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY P.O. Box 5811 INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE San Mateo CA1(415)1- SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED DATE FILED r h" �/ IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE (1) BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. ❑ III. F THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. ( THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM `B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. F RMA (3-2-88) fl�? - DATA PROCESSING COPY APPLICA T'S NAME (PRINTED & SIGNATURE) DATE Frances W. Hedrick -15 -0 �� A en for ARCO 1 LOCAL AGENCY USE ONLY Barghausen Consulting Engineers, Inc. (916) 348-3057 COUNTY # JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE U I / 1-71 U L L 0 I U I L) CURRENT LOCAL AGENCY FACILITY ID # / APPROVED BY NAME PHONE # WITH AREA CODE PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATIONO E 17 CENSUS TRACT # SUPERVISOR-DISTRICT ODE BUSINESS PLAN FILED DATE FILED r h" �/ V k U YES ❑ NO y-�0 CHECK # PERMIT AMOUNT SURCHARGE AMOU T FEE CODE RECEIPT # BY: