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STATE OF CALIFORNA M1�s° •, c�? <br /> STATE WATER RESOURCES CONTROL BOARD W mom, <br /> f, UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMT O 3 RENEWAL PERMIT ED 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED STE <br /> ONE ITEM a 2 INTERIM PERMIT 4 AMENDED PERMIT O 6 TEMPORARY SITE CLOSURE LIE 2 <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> FACILITY/SITE CARE OF ADDRESS INFORMATION <br /> ARCO Facility # 6020 Gary Burigin <br /> ADDRESS NEAREST CROSS STREET <br /> 1711 E. Yosemite Avenue Highway 99 <br /> CITY NAME STATE ZIP CODE SITE PHONE a WITH AREA CODE <br /> Manteca CA 95336 1 (209)823-471 <br /> v BOX <br /> TO INDICATE IX CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> TYPE OF BUSINESS GAS STATION O 2 DISTRIBUTOR Q ✓ IF INDIAN 4 E.P.A. L D.A(aWwal) <br /> RESERVATION <br /> Q 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS a OF TANKS AT SITE CAL 000513016 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Gary Burgin (209)823-4715 ARCO Maintenance 1571-2427,28,29 <br /> NIGHTS: NAME(LAST,FIRST) PHONE s WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> Same Same Same (800) 451-9442 <br /> If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Atlantic Richfield Company Environmental <br /> MAILING OR STREET ADDRESS ✓ box b nd"m Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> 2000 Alameda de las Pulgas CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE aWITH AREA CODE <br /> San Mateo CA 94403 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Atlantic Richfield Company Environmental Com lian <br /> MAILING OR STREET ADDRESS ✓box b tdkam Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> P.O. BOX 5811 CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE aWITH AREA CODE <br /> San Mateo ICA 94403 1571-2407 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notHication 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND <br /> CORRECT <br /> APPLICANTSNAME(PRINTED&SIGNATURE) Frances W. Hedrick DATE <br /> Agent for ARCO 1 10-4-90 <br /> Barghausen <br /> - <br /> Barghausen Consulting Engineers, Inc. (916) 348-3057 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY ID A #OF TANKS AT SITE <br /> m d C, � f10 1010 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT a -OPTIONAL SUPVISOR-DISTRICT CODE -OPTIONAL �w\ <br /> C2- <br /> THIS FORM MUST BE ACCOMPANIED BY AT LE' (1)OR MORE PERMIT APPLICATION• FORM B, UNLEP"THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(1-90) A <br /> �. � ) r) <br />