COMPLIANCE INFO_1986-1996 - Laserfiche WebLink

Home Browse Search

J 0 66�q C STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY t NEW PERMIT 3 RENEWAL PERMIT FM 6 CHANGE OF INFORMATION D 7 PERMANENTLY CLOSED SITE ONE RO Q ry EM 2 INTERIM PERMIT 4 AMENDED PERMIT 8 TEMPORARY SITE CLOSURE / 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR ARCO Facility 548 Mohammad A. Taeb ADDRESS NEAREST CROSS STREET PARCEL # (OPTIONAL) 1612 Hammer Lane Brentwood Ave- 077-28-2 CITY NAME STATE ZIP CODE SITE PHONE # WITH AREA CODE Stockton CA 1 95207-..1209),478-2723 Artesia TO INDICATE lX CORPORATION INDIVIDUAL 0 PARTNERSHIP F-1 LOCAL -AGENCY COUNTY -AGENCY' F7 STATE -AGENCY' 0 FEDERAL -AGENCY' DISTRICTS' ' M owner of UST is a public agency, complete the following: name of Supervisor of division, section, or office which operates the UST TYPE OF BUSINESS ® t GAS STATION 0 2 DISTRIBUTOR # OF TANKS AT SITE E. P. A. I. D. # (optional) Q 3 FARM 4 PROCESSOR Q 5 OTHER RESEIF RVATION kT OR TRUST LANDS CAL 000028349 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE Taeb Mohammad 209 478-2723 Duty Manager 209 478-2723 NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE ARCO Maintenance 800 272-6349 ARCO Maintenance 272-6349 It. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) NAME ARCO Products QmpaU CARE OF ADDRESS INFORMATION Environ Health Safety MAILING OR STREET ADDRESS ✓ box to indicate [—I INDIVIDUAL 0 LOCAL -AGENCY STATE -AGENCY P.O. BOX 6038 EX CORPORATION 0 PARTNERSHIP COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE CITY NAME PHONE # WITH AREA CODE Artesia I CA 1 90702-6038 Artesia 714 670-5404 111. TANK OWNER INFORMATION - (MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION DATE MONTH/DAYNEAR ARCO Products Cornijany Environ. Health & Safety MAILING OR STREET ADDRESS ✓ box loindicate 0 INDIVIDUAL Q LOCAL -AGENCY STATE -AGENCY P.O. BOX 6038 10 CORPORATION (] PARTNERSHIP Q COUNTY -AGENCY FEDERAL -AGENCY CITY NAME STATE ZIP CODE PHONE # WITH AREA CODE Artesia I CA 1 90702-6038 7714 670-5404 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. TY (TK) HQ4 4- - 0 0 5 0 6 V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED ✓ boxbindicate KI t SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE E::] 4 SURETY BOND E::] 5 LETTER OF CREDIT Q 6 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. El it. ED 111. a THIS FORM HAS BEEN Cq pI FETED UNDER RENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT OWNE ME (PRINTED &SIGN OWNER'S TITLE DATE MONTH/DAYNEAR Pro'ect Architect LOCAL AGENCY USE ONLY Thomas Schoenstein - Tait & Associates COUNTY # JURISDICTION # FACILITY # Fad 71 LOCATION CODE -OPTIONAL CENSUS TRACT # - OPTIONAL SUNISOR - DISTRICT CODE - OPn0ML THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. OWNER MUST FILE THIS FORW THE LOCAL AGENCY IMPLEMENTING THE UNDERGROVAGETMKRECULATKM FORM A (3193) FOROMM-117