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�6OUN e <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLIPATIpN- FORM Af J [[_� l w baa <br /> PEF, IT/S" <br /> ���{, 'EIR <br /> ji I^; CSI IFpN N� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F_� 1 NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION [:] 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM E] 2 INTERIM PERMIT F7 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ARCO FAC#-.' 595 Mercedes L. Acosta <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 6100 North Hwy 99 Hammer Lane <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95205 209-931-5976 <br /> TO DIC TE CORPORATION [[R� INDIVIDUAL ED PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION O 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM 4 PROCESSOR a 5 OTHER OR TRUST LANDS 3 CAL 000 028 355 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 800-272-6349 <br /> Acosta Mercedes 209-931-5976 Arco Maintenance <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 800-272-6349 <br /> Arco Maintenance 800-272-6349 Arco Maintenance <br /> PHONE#WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Madeline Scannavino Madeline Scannavino <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY <br /> STATE-AGENCY <br /> 5463 Cherokee Blvd CORPORATION PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton CA 95205 310-404-5385 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Arco Products Company Environmentpl Health & Safety Dept. <br /> MAILING OR STREET ADDRESS ;c✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 17 315 Studebaker Rd. [ ]CORPORATION PARTNERSHIP 0 COUNTY.AGENCY FEDERAL-AGENCY <br /> CIN 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 EX 1 SELF-INSURED E=]2 GUARANTEE E=] 3 INSURANCE 4 SURETY BOND <br /> 0 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 /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it. III. <br /> THIS FORM HAS BEEN COMPLET,EP UNDER PEN TY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> Daniel B. Goa JW <br /> in <br /> Consultant B.C.E. Inc 2/1/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL 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 Y. <br /> FORM A(5-91) 03 A-5 <br /> Preparer: Barghausen C— sulting Engineers Inc . ; ( I <br /> 4612 Roseville Rd. , N( .Z Highlands , CA 95660 <br /> 18215 72nd Ave. South, Kent, WA 98032 <br />