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STATE OFCALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION'. FORMA.. <br /> - 01 Y' 1 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c•`"O"" <br /> MARK ONLY L— 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION �7P:ERMANENTLY CLOSED SIT <br /> JA <br /> ONE ITEM 2 INTERIM PERMIT Jl 4 AMENDED PERMIT J 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ARCO FAC r 595 Mercedes L. Acosta <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 6100 North Hwy 99 Hammer .T,ane <br /> CITY NAME STATE ZIP CODE SITE PHONE*WITH AREA CODE <br /> Stockton CA i 95205 209-931-5976 <br /> ✓ Box <br /> TO INDICATE n CORPORATION Ck� INDIVIDUAL PARTNERSHIP LOCAL-AGENCY =j COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS Ey 1 GAS STATION ;—' 2 DISTRIBUTOR I� ✓ IF INDIAN Is OF TANKS AT SITE E.P.A. I.D=(optionai) <br /> 3 FARM J d PgOCESSOR 5 OTHER RESERVATIONOR TRUST LANDS 3 CAL 00 <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) <br /> Arco Maintenance 800-272-6349 Arco Maintenance 800-272-6349 <br /> PHONE#WITH AREA <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME j CARE OF ADDRESS INFORMATION <br /> Madeline Scannavino (Madeline Scannavino <br /> `RAILING OR STREET ADDRESS f ✓ box 10 indicate <br /> 5463 Cherokee Blvd J INDIVIDUAL LOCAL AGENCY — STATE-AGENCY <br /> a CORPORATION PARTNERSHIP 7—. COUNrY-AGENCY __7 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Stockton CA ! 95205 i; 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 ✓ box toind"o = INDIVIDUAL 77 LOCAL-AGENCY r <br /> STATGFNCY <br /> 17315 Studebaker Rd. FEDERAL-AGENCY CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITU NAME I STATE ZIP CODE PHONE#WITH AREA CODE <br /> Cerritos I - CA 90701 310-407-2605 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if quesfions arise. <br /> TY(TK) HQ 744 - 0 0 0 5 0 6 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHODS) USED <br /> ✓ box b indicate [I SELF-INSURED 2 GUARANTEE " 3 INSURANCE U 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION J 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: 1.1-7, II.i—I III.I <br /> THIS FORM HAS BEEN COMPLET 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 MONTWDAY/YEAR <br /> Daniel B. Goalwinr Consultant B.C.E. Inc 2/1/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY* JURISDICTION# FACILITY# <br /> I <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL i SLIPVISOR-DISTRICT CODE -OPTIONAL <br /> 1 <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(t)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION Ftk AAs <br /> FORMA(5-91) <br /> Preparer: Barghausen Cr sulting Engineers Inc. ; <br /> 4512 Roseville Rd - , NL a Highlands, CA 95660 �. <br /> 18215 72nd Ave . South, Kent , WA 98032 ~ <br />