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.a.°"� � =3 s+� fib• rr� � , v �` ^.'�4 �t7V�'ifx, a �'; +` - - � r <br /> STATE OF CALIFORNIAAl <br /> e STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA a x <br /> I� �.0 v' x"� ,'b`+' `,` µ`iv "�t`a K .."�° .' - _�� 4�r(•t 3'Y <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> r"" <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT O 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 72 INTERIM PERMIT 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> = DBA OR FACILITY NAME _ �,t NAME OF OPERATOR <br /> ARCO FAC <br /> ADDRESS ` NEAREST GROSS STREET <br /> PARCEL#(OPTIONAL) s <br /> G c .''_r a 7 di i vc <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> � 3 <br /> ... mom. CA 37f 16 01 <br /> ✓ BOX <br /> y. TO INDICATE O CORPORATION Fn, INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR o ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> ' 3 FARM 0 4 PROCESSOR 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional w° <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 800-272-6349 <br /> d � <br /> 09-93 o- 60 5 Arco Maintenance <br /> NIG TS: NAM /LAST FIRST) s PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> Arco maintenance 800-272-6349Arco Maintenance 800-272-6349 <br /> PHONE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLTO <br /> NAME CARE OF ADDRESS INFORMATION "ft" <br /> Atlantic Richfield Company Environmental Health & Safety Dept. va <br /> MAILING OR STREET ADDRESS ✓box to indicate INDIVIDUAL LOCAL-AGENCY D STATE-AGENCY ` <br /> 17315 'RStudebaker Rd• CORPORATION PARTNERSHIP 0 COUNTY-AGENCY ( FEDERAL-AGENCY , <br /> CITY NAME STATE ZIP CODE PHONE#Wit TH AREA CODE T <br /> ' Cerritos CA 90701 310-407-2605 <br /> III. TANK OWNER INFORMATtQI -(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 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY Y;; <br /> 17315 Studebaker Rd• CORPORATION PARTNERSHIP 0 COUNTY-AGENCY 0 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 0 0 5 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate ] I SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT Q <br /> APPLICANT'S NAME(PRINTED 8 SIGNATU ) APPLICANT1'S TITLE DATE MONTH/DAY YEAR <br /> Daniel B. GoalFiin - Consultant B.C.E.Inc 2/11/92 <br /> LOCAL AGENCY USE ONLY <br /> 3 <br /> COUNTY# JURISDICTION# FACILITY# <br /> 1 <br /> LOCATION CODE -CJPTIONAt 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) FOR0033A5 <br /> Preparer: Barghausen Consulting Engineers Inc . <br /> 4612 Roseville Rd. , rth Highlands , CA 95660 s <br /> " :18215 72nd Ave . South , Kent , WA 98032 <br />