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..t `6ppR t <br />' STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD F tlr Ab <br />S <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE C4�fORN'' <br />I NEW PERMIT 3 RENEWAL PERMIT 6 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br />MARK ONLY_,_. , <br />ONE ITEM O 2 INTERIM PERMIT Q 4 AMENDED PERMIT EJ a TEMPORARY SITE CLOSURE <br />I FACII ITYISITF INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />ARCO Facility 548 <br />Mohammad A. Taeb <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL 0 (OPTIONAL) <br />1612 Hammer Lane <br />Brentwood Ave. <br />077-28-2 <br />CIN NAME <br />STATE ZIP CODE <br />SITE PHONE fT WITH AREA CODE <br />Stockton I <br />CA <br />478-2723 <br />BOX <br />TO INDICTE EX CORPORATION ED INDIVIDUAL ED PARTNERSHIP 0 LOCAL -AGENCY 0 COUNTY.AGENCY • STATE -AGENCY 0 FEDERAL -AGENCY' <br />DISTRICTS' <br />II owner of UST Is a public agency, complete the following: name of Supervisor of division, section, or office which operates the UST <br />TYPE OF BUSINESS ® t GAS STATION Q 2 DISTRIBUTOR <br />O ✓ IF INDIAN <br />is OF TANKS AT SITE <br />E. P. A. 1. D. # (optional) <br />0 3 FARM 0 4 PROCESSOR 0 6 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />4 <br />CAL 000028349 <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - ootlonal <br />DAYS: NAME (LAST, FIRST) <br />PHONE x WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />Taeb Mohammad <br />9 478-2723 <br />Duty Manager <br />20 478-2723 <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />ARCO Maintenance <br />STATE <br />AEM Maintenance272-6349 <br />II PAnPFRTV nWNFR INFnRMATION - (MIIST RF COMPLFTFD) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />DATE MONTH/DAYNEAR <br />ARCO Products Companyiron. <br />Realth & <br />Safety <br />MAILING OR STREET ADDRESS <br />✓ box blrdfcate . 0 INDIVIDUAL <br />0 LOCAL -AGENCY 0 STATE -AGENCY <br />P.O. X 6038 <br />EX CORPORATION 0 PARTNERSHIP <br />0 COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />Artesia <br />CA <br />1 90702-6038 <br />714 670-5404 <br />III. TANK UWNEH INFUHMAI IUN - (MU5I UI: GUMFLEII:U) <br />NAME OF OWNER I CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS ✓ box toIrftate E] INDIVIDUAL Q LOCAL -AGENCY [�j STATE -AGENCY <br />P.O. BOX 6038 X] CORPORATION Ij PARTNERSHIP O COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME STATE I ZIP CODE I PHONE # WITH AREA CODE <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ M44- - 0 0 0 5 i 161 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box b Indicate KI 1 SELF-INSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br />0 5 LETTER OF CREDIT 0 6 E*MPTION El In 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: L O II.O III. DO <br />THIS FORM HAS BEEN CT7TED UNDEVENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />OWNE ME (PRINTED & SIGN <br />OWNER'S TRLE <br />DATE MONTH/DAYNEAR <br />- <br />Pro'ect Architect <br />LOCAL AGENCY USE ONLY Thomas Schoenstein - Tait & Associates <br />COUNTY # JURISDICTION # FACILITY # <br />m <br />LOCATION CODE -OPTIONAL I CENSUS TRACT a . OPTIONAL I 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 />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br />FORM A (3193) FOR0033A-R7 <br />