Laserfiche WebLink
Jun-28-99 11 : 41A ARCO PPODUCTS CO. 916 684 6250 P . 06 <br /> RATI of CAUPONGA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION •FORM A ; �P <br /> COMPLETE TMS FORM FOR EACM FACILITY/SITE <br /> MARK ONLY *VV PERMIT Q 3 AENEWAI PERMIT 6 CHAMM OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM [] 2 fNTERIM PGRMIT A Aor.NOGD PGRMIT O A TGyPORARY CITE C'XSURG <br /> I. FACILITY/SITE INFORMATION 6 ADDRESS•(MUST BE COMPLETED) <br /> NAME OF OOERATOA <br /> ffADC)RESS <br /> Y NAME mercedes L. Acosta <br /> FAC# 595 ` ,�C&LI(��ALI <br /> NEARETTCRM STAGET <br /> rth 99 Hamner LaneSTATE IJP CODE SFTE PHONEa WITH AREA CODE <br /> CA 9520______V___ 209-931-5976 <br /> n _----- <br /> rwTlFRew ❑ iocAL+wE►Icr ��cau+mr+DE1a r ❑ STATE (] FEDLAALaGEIICr <br /> TOwDCATE �COPPORATK)N [ 110 VDWL C WAICTS <br /> TYPE Of 6UlINES9 III:INOIAII a 0+:TANKS AT 9RE E.P,1 I,O.•(aw�a+Aq <br /> 1 GAS STATION 1 DISTAIeUTOR �] RESERVATION 000 028 355 <br /> 3 FARM Q A r110CEsS0A Q S OTHER OR TRUST LMOS 3 C <br /> AL EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•oWOonal <br /> DAYS' NAME(LAST,FIRST) PHONES V WITH MWA COOSDAYS: NAME MST.FIRST) 600-272—E-349- <br /> Azcc Maintenance <br /> Acogta, Mercedes 209-931-5976 N,�R cA� B00-272-639 , <br /> NKWTS: NAMF.ILAST.FIRE[1 800-272-6399 Arco Maintenance D <br /> Arco Maintenance 800-272-6349 <br /> I.I. PROPEFFTY OWNER INFORMATION• UST BE COMPLETED <br /> CARE OF AOOREE9 INFORMATION <br /> NAME Madeline SCa1mavin0 <br /> Madeline $CaS171dV1I10 eo.a O INDMduu LOCAL-AGENCY (�]sTAn.AOENcr <br /> MAILING OR STREET ADDRESS <br /> 5463 Cherokee Blvd O coRroruTraN p ►AagTNGRSNw � cDUNrr.ADENcr = F60EPIIutOENCr <br /> CITY NAME STATE Be,COOS -----�P-410N—E A WITH AREA GOOF <br /> CA 95205 310-404-5385 <br /> 01, TANK OWNER INFORMATION•(MUST BE COMPLETED <br /> NAME OF OWNER CAR!OF ADORE"aiW11MATIDN <br /> Arco Products Com an Environmentpl Health & Safety Dept. <br /> MAILING OR STREET ADDRESS 0aa 1AS <br /> UW = INDIVnUAL C.:: LOCAL-AUNCr C]SFATE-AGPCY <br /> 'R <br /> 73 15 Studebaker Rd. XD QDRPAT10h CD `A" WRIW L COVInAm"Cr L� FEDVIAL•AOENCY <br /> 1 <br /> CITY NAME STATE ZIP CGDE PNONG•WITH ARCA CODE <br /> Cerritos I . CA 90701 310-407-2605 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323.9555 If quasliors arise. <br /> TY(TK) HO F4-F4]. <br /> 0 0 0 5 0 6 <br /> V, PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> I SELF-04JUD 2 QARAK7EE LJo MSURANCG =.sURET11 Ba,o <br /> Yu a WICN. O S LFTTLA OF CM-DT Q a QEMPnON ❑fet OTHER <br /> VI. LEGAL NOTIFICATION AND 131LUNG ADDRESS Legal noli ka ion end billing will be sent to the lank owner unless box I a 111-3 chocked. <br /> CHECK ONE BOX INDICATING WNN31 ADOVE ADDRESS SHOULD M USED FOR LEGAL NOTIFICATIONS AND SILINO: <br /> I.n II,= SIL <br /> THIS FORM HAS BEEN COMPLEf UNDER PEN TY OF PERJURY,AND To TK-c BEST OF MY KNOWLEDCS,IS TRUE LINO CORRECT <br /> APPLICANTS NAME(PANTED&SICOLATUAfl��I �u/.J� <br /> APPUCANrs TTn.e �DA MONT ♦ryeA <br /> Davie Goa Consultant B.C.E_in 2/1/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY• JURLSDICTION a FACIL(TY t <br /> m � �I <br /> LOCATION COOS •OPTFONAL CENSUS TRACT •OPTIONA4 SUPVAOR•OISTRICT CODE •OPTIONAL <br /> TNS FORK MUST BE ACCOMPAMEo BY AT LEAST(1)OR MORE PERMIT APPUCA710N• FORM B,UNLESS THIS IS A C 11ANC£OF SIT6 INFORMATION ONLY,A 1 <br /> FORM A(5611 <br /> Preparer: Sarghausen Consulting Engineers Inc . ; <br /> 4612 Roseville Rd. , North Highlands , CA 95660 <br /> 19215 72nd Ave. South , Kent , WA 98012 0�bS0L9rLL S� rT 666Z/S7/90 <br /> co mnrya CW1dd C1 0:)6v SH3 <br />