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eyouR es <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD s , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - `<f `" '"_ �a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION r ISE M>iNE b <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME IiAtK ZP NAME OF OPERATOR <br /> "__= +' AM/PM MINI PIA-RT JACK ANASTASIO <br /> ADORE S NEAREST CROSS STREET PARCEL#(OPT IONAL) <br /> 725 TRacy Blvd Clove r Road <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Tracy CA 95376 209-835-1605 <br /> T DIC <br /> NTE O CORPORATION XX INDIVIDUAL =PARTNERSHIP 0 LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ® 1 GAS STATION = 2 DISTRIBUTOR / IF INDIAN 1#OF TA)(KS AT SITE E.P.A. t.D.#(optional) <br /> RESERVATION fie q <br /> 3 FARM = 4 PROCESSOR = 5 OTHER OR TRUST LANDS CAL 000 01 3 992 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CC TACT P ON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> ANASTASIO, JAC-. 209-035-1605 A "ICO LAIFE'LENANCE,, 800-11111CO FIX <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ARCO MAINTENANCE 800-ARCO—FIX ARCO MAINTENANCE 800—ARCO—FIX <br /> HONE#WITH AREA CODE <br /> IL PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ATLANTIC RICHFIELD CO. ENV. HEALTH AND SAFETY <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> P.O. X 6038 EX CORPORATION [] PARTNERSHIP COUNTY-AGENCY [] FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ARTESIA CA 90702 1310-407-2605 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ARCO PRODUCTS CO. ENV. HEALTH AND SAFETY <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL <br /> [] LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 6038 EX CORPORATION 0 PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> ARTESIA CA 90702 310-407-2".;" 5 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 0 I 0 I 0 I5 0 6 <br /> V. PETROLEUM UST F N'ANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ <br /> box to indicate 1 SELF-INSURED []2 GUARANTEE [] 3 INSURANCE 4 SURETY BOND <br /> 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: <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> tZLIC NTS NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> z <br /> ( CHESTER BENNET PROJECT MANAG Cj `13 <br /> OCAL AGENCY USE ONLY 1 '1( C <br /> COUNTY# ' (�� JURISDICTION# AGILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT -OPTIONAL SUPVISOR-DISTRICT CODE!-{��i1•D9;/QNA� <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 />