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Pe6OUR C <br />STATE OF CALIFORNIA �P <br />STATE WATER RESOURCES CONTROL BOARD M A' N/ <br />UNDERGROUND STORAGE TANK PERMIT APPLICA PN ,--FORMA Yp oe <br />�• / i, i ;�l E' < °4 iron N`� <br />wnnmr 1 r i rno renin rVn CNVn FMN II 11911 G <br />MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT © 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br />I.ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br />I�d�iail■rrt�{Oir1�1►17�1a1G/�\1[�1►�:7�1�1�1:1�.'1.'IIIPiDb'f■=13aia]IVI�\ala�ll <br />D� <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />ARCO FAC0 548 <br />Mohammed A Taeb <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL# (OPTIONAL) <br />1612 Hammer Lane <br />Brentwood <br />X1 CORPORATION 0 PARTNERSHIP <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />Stockton <br />CA <br />95207 <br />209-478-2723 <br />✓ BOX <br />TO INDICATE D CORPORATION E& INDIVIDUAL 0 PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY STATE -AGENCY 0 FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS E:y 1 GAS STATION 0 2 DISTRIBUTOR= <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />0 3 FARM a 4 PROCESSOR = 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />5 <br />CAL 000 0 2 8 349 <br />EMERGENCY CONTACT PERSON (PRIMARYI EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) 800-272-6349 <br />Taeb Mohammed <br />209-478-2723 <br />Arco Maintenance <br />NIGHTS: NAME LAST, FIRST) <br />Arco Maintenance <br />PHONE # WITH AREA CODE <br />800-272-6349 <br />NIGHTS: NAME (LAST, FIRST) <br />Arco Maintenance 800-272-6349 <br />PHONE # WITH AREA CODE <br />II DDr%DCDTV rN"1KIC0 IAIPn0IIAATIr11J . [RAI ICT RF (`r)RAP1 FTFr11 <br />NAME <br />CARE OF ADDRESS INFORMATION <br />DATE MONTWDAYNEAR <br />Atlantic Richfield Company <br />Environmental Health & Safety Dept. <br />MAILING OR STREET ADDRESS <br />✓ box to indicate 0 INDIVIDUAL <br />= LOCAL -AGENCY = STATE -AGENCY <br />17315 Studebaker Rd. <br />X1 CORPORATION 0 PARTNERSHIP <br />0 COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />Cerritos <br />CA <br />90701 <br />310-407-2605 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER CARE OF ADDRESS INFORMATION <br />;; r_• Products Company Environmental Health & Safety Dept. <br />V3i5 <br />STREET ADDRESS ✓ box to indicate = INDIVIDUAL = LOCAL -AGENCY 0 STATE -AGENCY <br />Studebaker Rd • ]g—] CORPORATION = PARTNERSHIP = COUNTY -AGENCY = FEDERAL -AGENCY <br />CI AME STATE ZIP CODE PHONE # WITH AREA CODE <br />Cerritos CA 1 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 0 6 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box to indicate1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br />A 5 LETTEROFCREDIT 6 EXEMPTION 0 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: 1. <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 <br />APPLICANTS TITLE <br />DATE MONTWDAYNEAR <br />D - <br />Consultant B.C.E.Inc <br />2/11/92 <br />LOCAL AGENCY USE ONLY <br />COUNTY # <br />✓TRACT <br />JURISDICTION # <br />FACILITY # <br />LOCATION CODE -QPTIONAL <br />CENSUS # -OPTIONAL, `, j_ <br />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 ONLY. <br />FORM A (5-91) FOR0033A-5 <br />Preparer: Barghausensulting Engineers Inc.; <br />4612 Roseville Rd., *h Highlands, CA 95660 <br />18215 72nd Ave. South, Kent, WA 98032 <br />