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. 6OUR C <br /> STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND T AGE TANK PERMIT LI TIO40 <br /> R s.i "1� a <br /> t�v x,�k s �.;� . I f yy 88 �_d o <br /> PER,M�x' 418 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE oRN' <br /> MARK ONLY 0 1 NEW PERMIT O 3 RENEWAL PERMIT F_X� 5 CHANGE OF INFORMATION O 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM F—] 2 INTERIM PERMIT F-1 4 AMENDED PERMIT [::] 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ARCO FAC#.+ 2093 Jack L. Anastasio <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3425 Tracy Blvd Clover <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Tracy CA 95376 209-835-1605 <br /> ✓ BOX <br /> TO INDICATE D CORPORATION FX INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY (] FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS �; 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION 3 <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS <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 /> Anastasio, J.L. 209-835-1605 Arco Maintenance <br /> NIG T M LAST FIRS 6HT3#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ' cN�S' in'ten�ance 80�-D22-6349 Arco Maintenance 800-272-6349 <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Atlantic Richfield Company Environmental Health & Safety Dept. <br /> MAI ING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY O STATE-AGENCY <br /> �7 315 Studebaker Rd• Pt CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Cerritos CA 90701 310-407-2605 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> Arco Products Com an. Environmental Health & Safety De t. <br /> MAILING OR STREET ADDRESS ✓ box IDindicate INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> 17315 Studebaker Rd. CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Cerritos CA 90701 1310-407-2605 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. . <br /> TY(TK) HQ 4 4 - 0 lo lo I5 0 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate {� 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT 6 EXEMPTION Q 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.E:1 II.F� ill. <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&SIGNATU ) APPLICANTS TITLE DATE MONTH/DAY/YEAR <br /> Daniel B. Goalx4in Consultant B.C.E.Inc 2 11/92 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> I <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: Barghausen Consulting Engineers Inc. <br /> 4612 Roseville Rd. Orth Highlands, CA 95660 <br /> 18215 72nd Ave. Sou n, Kent, WA 98032 <br />