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..,�-• Il�,PF^n �.P. ... .n <br /> STATE OF CALIFORNtt�.M WATER RESOURCES CONTRR4BOARD 'o; <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑X 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY T <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> IO <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION Prestige Stations, Inc. <br /> ARCO AM/PM Mini-market 17215 Studebaker Rd. Cerritos, CA 90701 W <br /> ADDRESS NEAREST CROSS STREET ✓Bo,to iMMgle ❑ PARTNERSHIP ❑ STATE AGENCY <br /> Lower Sacramento Road Indiana Street D INDIVIDUAL ❑ COUNTY <br /> OGALAGe EN ❑ EOERA.AGENa <br /> ❑ INDIVIDUAL ❑ LO LAAGENCf _ <br /> CITY NAME STATE ZIP CODE SITE PHONE IL WITH AREA CODE <br /> Woodbridge, CA N/A <br /> TYPE OF BUSINESS. ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box ii INDIAN EPA ID 4 Nat TAMP% <br /> ® 1 GAS STATION ❑ 3 FARM ❑ TRUSTLANDS <br /> 5 OTHER RESERVATION or ❑ N/A AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE M WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA ODE <br /> Ng, Mitchell 213-402-1299 ARCO Maintenance 415-571-2427 <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> same 800-553-6246 same 800-451-9442 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF DDRESS INFORMATION <br /> ARCO Products Company A)M <br /> MAILING or STREET ADDRESS ed�✓1p Box to indloate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ FEDERAL-AGENCY <br /> 2000 Alameda de las Pul as INDIVIDUAL 0 COUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> San Mateo, CA 1 94403 415-571-2407 <br /> 111. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF�^DORESS INFORMATION <br /> ARCO Products Company N/R <br /> MAILING or STREET ADDRESS ✓Box to intlicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> P.O. BOX 5811 ❑ INDIVIDUAL ION ❑ COUNTY-AGENCY <br /> D LOCAL-AGENCY 13 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE A,WITH AREA CODE <br /> San Mateo CA 94402 415-571-2407 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ IL ❑ III. <br /> EK <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&SIGNATURE) DATE <br /> Peter B. Tobin 4-24-89 <br /> LOCAL AGENCY USE ONLY AST RAP-hh~ 46AI& <br /> COUNTY11 JURISDICTION N AGENCY M FACILITY ID 11 M of TANKS H SITE <br /> 39I DC)4 1 3g 0003 <br /> CURRENT L;FL�DE[1C�FACAITY�IDTe APPROVED BY E PHONE N WITH AREA CODE <br /> PERMIT NUMBER /�`J /1l &,LL1 �O[ PERMIT APPROVAL DATE PE MIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRA K SUPERVISOR-DISTINCT CODE BUSINESS PLAN FILED DAT ILE <br /> 4G 1�' 1) (//q <br /> YES NO $� <br /> CHECK• /. PERM AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPTM BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION($),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> ;1� DATA PROCESSING COPY \w <br />