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esoun es <br /> STATE OF CALIFORNIA ? �° <br /> STATE WATER RESOURCES CONTROL BOARD ' <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM MAY 1 <br /> Pl VIRONMENT <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE mrONA17 I <br /> MARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION [::] 7 PERMANENTLY CLOSED <br /> ONE ITEM F7 2 INTERIM PERMIT 0 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE G/ / <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ARCO FAC#-.' 6020 Gary L. Burgin <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1711 E Yosemite Hwv 99 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Manteca CA 95336 209-823-4715 <br /> ✓ BOX <br /> TO INDICATE E=1 CORPORATION IX INDIVIDUAL = PARTNERSHIP E:1 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS [::4 1 GAS STATION 0 2 DISTRIBUTORR SEF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS 3 CAL 000 043 382 <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 /> Burgin, Gary 209-823-4715 Arco Maintenance PH )DF <br /> NIG TS: NA LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> �rco"'l intenance 800-272-6349 Arco Maintenance 800-272-6349 <br /> PHONE#WITH AREA COQF <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Atlantic Richfield Company Environmental Health & Safety Dept. <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> 17 315 Studebaker Rd. CORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Cerritos CA 90701 310-407-2605 <br /> A` 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 Q LOCAL-AGENCY = STATE-AGENCY <br /> 17 315 Studebaker Rd. CORPORATION PARTNERSHIP COUNTY-AGENCY 0 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 oindicate 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 0 6 EXEMPTION 0 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.❑ II.F] 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/DAYNEAR <br /> Daniel B. Goalx4in Consultant B.C.E.Inc 2/1/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> Ips <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 ONLY. <br /> FORM A(5-91) FOR0033A-5 <br /> Preparer: Barghause* Isulting Engineers Inc . ; <br /> 4612 Roseville Rd. , th Highlands , CA 95660 <br /> 18215 72nd Ave . South , Kent , WA 98032 <br />