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w�eoo^ <br /> STATE OF CALIFORNIA - ,? `4 <br /> STATE WATER RESOURCES CONTROL BOARD i <br /> MAY 1 � 152 ���•- <br /> UNDERGROUND STORAGE TANK PERMIT APPLICRA� 10 -NjR1 41 4A HEAL ,H <br /> E PERMIT/SERVICES ��.o.�� <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY F-1 1 NEW PERMIT O 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED <br /> ONE ITEM 0 2 INTERIM PERMIT F__1 4 AMENDED PERMIT Q a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ARCO FAC(..' 4493 John H. Ittner <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPr10NAL) <br /> 205 North Center Street Channel <br /> CIN NAME STATE ZIP CODE SITE PHONE♦WITH AREA CODE <br /> Stockton CA 95202 209-948-0838 <br /> TOO INDICATE D CORPORATION [X INDIVIDUAL =PARTNERSHIP l�LOCAL-AGENCY O COUNTYAGENCY O STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS E:Ii: 1 GAS STATION O 2 DISTRIBUTORO ✓ IF INDIAN x OF TANKS AT SITE E.P.A. I.D.a(0Pd0r l) <br /> RESERVATION 3 <br /> O 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-opllonal <br /> DAYS: NAME(LAST,FIRST) PHONE x WITH AREA CODE DAYS: NAME(LAST,FIRST) 800-272-6349 <br /> Ittner, John 209-948-0838 jArco Maintenance <br /> NIG r: o M T,tRST) H 22WHAREACODE NIGHTS: NAME(LAST,FIRST) <br /> nenance 806- - 349 Arco Maintenance 800-272-6349 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Atlantic Richfield Company Environmental Health & Safety Dept. <br /> MAILING OR STREET ADDRESS ✓box 10 mica INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> ,;F <br /> 17315 Studebaker Rd. �CORPORATION Q PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> "19'07011 <br /> IP CODE PHONE x WITH AREA CODE <br /> CITU NAME STATE <br /> Cerritos CA 90701 310-407-2605 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Arco Products Company Environmental Health & Safety Dept. <br /> MAILING OR STREET ADDRESS ✓ boblMicab = INDIVIDUAL O LOCAL-AGENCY STATE-AGENCY <br /> 17315 Studebaker Rd. ND CORPORAnON 0 PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE c 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 it 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 blmb w1 SELF-INSURED O2 GUARANTEE 0 3 INSURANCE 04 SURETY BOND <br /> S LETTEROFCREDIT 0 5 EXEMPTION 0 W 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.O II.O Ill. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PA INTED&SIGNATUR APPLICANTS TITLE DATE MONTHIDAWYEAR <br /> Daniel B Goalkin - Consultant B.C.E.Inc 2/1/92 <br /> LOCAL AGENCY USE ONLY <br /> C0UNTY x JURISDICTION# FACILffYN /I�z <br /> LOCATION CODE -OP l NAL CENSUSTRACO, T NAL SUPVISOR-DISTRICT CODE- IOP—i1 WALL Jf <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 /> IRM A(5-91) �/(/% i FOR0033A-5 <br /> Preparer: Barghausen -isulting Engineers Inc. ; <br /> 1612 Roseville Rd. , N`_.och Highlands, CA 95660 <br /> 8215 72nd Ave. South, Kent , WA 98032 <br />