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STATE OF CALIFORNIA MAY 1 9 <br /> STATE WATER RESOURCES CONTROL BOARD NTAL , <br /> r fail/fit-�fl TI ,/SERVI DERGROUND STORAGE TANK PERMIT APPLICA N - <br /> COMPLETE THIS FORM FOR EAC CILITY/SITE <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMA S D <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ARCO FAC#-.' 5469 _ W N Food Store Inc II <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 130 South Wilson Way Washington <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95205 209-466-6633 <br /> ✓ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ', 1 GAS STATION ❑ 2 DISTRIBUTOR / IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 <br /> E ENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAY . AME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 800-272-6349 <br /> /N Store, Inc. II 209-466-66 Arco Maintenance <br /> G TS: NAM LAST, IRST) HONE#WITH ARE DE NIGHTS: NAME(LAST,FIRST) 800-272-6349 <br /> PHONE#WITH AREA CODE <br /> coainenance 80�-272- Arco Maintenance <br /> II. P OPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NA CARE OF ADDRESS INFORMATION <br /> Atlantic d Company Environmental Health & Safety Dept. <br /> M STREETADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> Y 315 Studebaker Rd• ]CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY ME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Cer 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 ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 17315 Studebaker Rd. CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Cerritos CA 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 indicate 1 SELF-INSURED 0 2 GUARANTEE (] 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTER OF CREDIT =6 EXEMPTION 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 /> FCHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III. <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 ) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> Daniel B. GoalFlin - Consultant B.C.E.Inc 2/1/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# #MCA/ <br /> FU L <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL <br /> 0/ <br /> 6;;1, 3 �vd- <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- <br /> Preparer: Barghausen nsulting Engineers Inc. ; j'�/ <br /> 4612 Roseville Rd. , D th Highlands, CA 95660 ( 6� <br /> 18215 72nd Ave . South , Kent , WA 98032 <br />