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'eboun e c <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICAT �<N A!'[/`;L C <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F__] 1 NEW PERMIT 0 3 RENEWAL PERMIT FX–] 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F__j 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 FACS.+ 2133 John Stacfnaro <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 2908 Benjamin Holt Dr. Pl mouth <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95207 209-478-5552 <br /> ✓ BOX <br /> TO INDICATE Q CORPORATION F_X INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN I#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> Q 3 FARM Q 4 PROCESSOR Q 5 OTHER OR TRUST LANDS �j CAL 000 048 680 <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 /> Sta naro John 209-478-5552 Arco Maintenance,, <br /> NIG TS: NAM LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 800-272-6349 <br /> rco Maintenance 800-272-6349 Arco Maintenance <br /> PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> tjIlIM <br /> E CARE OF ADDRESS INFORMATION <br /> tlantic Richfield Company Environmental Health & Safety Dept. <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 17315 Studebaker Rd• P�j CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Cerritos CA 90701 310-407-2605 <br /> .j1.',,TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> OF OWNER CARE OF ADDRESS INFORMATION <br /> Arco Products CompanV Environmental Health & Safety Dept. <br /> MAILING OR STREET ADDRESS ✓ box to indicate Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 111,3115 Studebakex Rd• X]CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q 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) HQ4 4 - 0 10 10 5 0 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box b indicate 1SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br /> 5 LETTER OF CREDIT Q 6 EXEMPTION Q 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 cher,,, <br /> [CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. 11.0 <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 I...Z1—i-�# ^ � JURISDICTION# FACILITY <br /> LOCATION CODE 6, 7`1ONAL CENSUS TRACT# OPTIONAL SUPVISOR-DISTRICT C E -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 !LY. <br /> FORM A(5-91) OR0033A-5 <br /> Preparer: Barghausen C ulting Engineers Inc . , <br /> 4612 Roseville Rd. , NS Highlands , CA 95660 <br /> 18215 72nd Ave . South, Kent , WA 98032 <br />