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STATE OF CALIFORNIA .P <br />1 STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />• C�(If pq N,r <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION F__j 7 PERMANENTLY CLOSED SITE <br />ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br />I cAr%ll ITV/CIT;: IMPOPMATION R ®DDRFSS . (MUST RE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />ARCO AM PM Facility 5450 <br />Edward A Isaacson <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAW <br />1617 W. Fremont <br />I-5 <br />135-11-15 <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />Stockton <br />CA <br />95203 <br />209 462-1617 <br />TO INDICATE CM CORPORATION Q 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 <br />(714) 670-5404 <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />Q 3 FARM Q 4 PROCESSOR Q 5 OTHER <br />RESEIF RVADION <br />OR TRUST LANDS <br />3 <br />CAL 921724574 <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) • optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) <br />Isaacson Edward <br />209 462-1617 <br />Duty Manager (2 - <br />NIGHTS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />ARCO Maintenance <br />0 272-6349 <br />ARCO Maintenance <br />II DRnaFRTV OWNER INFOPMATir)N . (Ml1ST RF COMPLFTFDI <br />NAME <br />a.. •,► r ,l� <br />CARE OF ADDRESS INFORMATION <br />DATE MONTHIDAYNEAR <br />ARM Products Company <br />Environ. 1 & <br />Safety <br />MAILING OR STREET ADDRESS <br />✓ box to indicate Q INDIVIDUAL <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />P.O. Bax 6038 <br />FX CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />PHONE # WITH AREA CODE <br />Artesia <br />CA <br />90702-6038 <br />(714) 670-5404 <br />rer, ff a m 9 Tzftwer,1T rm, <br />NAME OF OWNER <br />CARE OF ADDRESS INFORMATION <br />DATE MONTHIDAYNEAR <br />ARCO Products Qgmpany <br />Environ. Health & <br />Safety <br />MAILING OR STREET ADDRESS <br />✓ box to indicate Q INDIVIDUAL <br />Q LOCAL -AGENCY Q STATE -AGENCY <br />P.O. Box 6038 <br />EX CORPORATION Q PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE ZIP CODE <br />PHONE # WITH AREA CODE <br />Artesia <br />CA 90702-6038 <br />(714) 670-5404 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ 4 4 - <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ boxbindcate ['X 1 SELF-INSURED Q 2 GUARANTEE Q 3 INSURANCE Q 4 SURETY BOND <br />Q 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 checked. <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ it. [:] III. <br />T3S FORM HAS BEEN C&PLETED LINDE'� PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />(PRIINNTED,&� R, <br />APPLICANTS TITLE <br />DATE MONTHIDAYNEAR <br />[APPLS'iA �jME <br />L <br />Project Architect <br />LOCAL AGENCY USE ONLY Thomas sctioenstein - vait & Associates <br />COUNTY # JURISDICTION # FACILITY # <br />m <br />LOCATION CODE - OPTIONAL ICENSUS TRACT # - 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 />FORM A (5-91) FOR0033A-5 <br />