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I IAIICICII oonr-`n ARO rr-mien1 Irl ATcn IIIRA TANKS UNDERGROUND STORAGE TANKS - FACILITY (one page per site) Page 1 of 1 TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3 RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑4 AMENDED PERMIT specify change local use only _ ©8 TANK REMOVED ❑63EMPORARY SITE CLOSURE 400 I. FACILITY/SITE INFORMATION BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 Arco#0760, 225 S. Cherokee Ln, Lodi, CA NEAREST CROSS STREET 401 FACILITY OWNER TYPE El 4. LOCAL GENCY/DISTRICT` ® 1.CORPORATION El 5.COUNTY AGENCY' East Lodi Ave BUSINESS N 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6. STATE AGENCY' TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3. PARTNERSHIP [17.FEDERAL AGENCY' 402 TOTAL NUMBER OF TANKS-- -" Is facility on Indian Reservation or `If owner of UST is a public agency:name of supervisor of division,section or office REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) 0 404 ❑ Yes ® No 405 406 II. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE 408 Arco Products Company 714 670-5300 MAILING OR STREET ADDRESS aos 4 Centerpointe Drive CITY 410 STATE 411 ZIP CODE 412 La Palma CA 90623-1066 PROPERTY OWNER TYPE ®1.CORPORATION ❑2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17. FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 Arco Products Company 714-670-5300 41s MAILING OR STREET ADDRESS 4 Center ointe Drive CITY 417 STATE 418 ZIP CODE 419 La Palma CA 90623-1066 TANK OWNER TYPE ®1.CORPORATION ❑2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6. STATE AGENCY 420 ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY (TK) HQ all (9 6) 322-9669 if auestions arise 421 V. PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE ❑1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM METHOD(s) [j2.GUARANTEE El 5,LETTER OF CREDIT ❑8-STATE FUND&CFO LETTER EI 99.OTHER: ❑3. INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD - 422 VL LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. Legal 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 VII.APPLICANT SIGNATURE LCertification-I certify that the Information provided herein is true and accurate to the best of my knowledge. --- - 424 FHONE a< SIGNAT E OF APRLICANT/ D11 91 ti ., 209 23` 240 � r. ------ - t. ME OF APPLICANT(print) -�� -"=E TITLE OF APPLICANT Gwen Birdsong 3 Office Mgr,K.E. Curtis Construction Co.,Inc. S i ATE UST FACIt 1?"Y NUMBER(ro local use only) 42b 1998 UPGRADE.CERTIFICATE NUtv1BER(FU lo.a!cs:rnl;