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, pP.S00 <br />R � C <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM ,,4V � p ,N „W'� °STH <br />COMPLETE THIS FORM FOR EACH FACILITYISITE <br />ES <br />MARK ONLY 1 NEW PERMIT F_� 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SM, <br />ONE ITEM 0 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 <br />NAME OF OPERATOR <br />ARCO FACT 5450 <br />Edward A. Issacson <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />1617 West Fremont <br />I-5 <br />STATE <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />Stockton <br />CA <br />95203 <br />209-462-1617 <br />✓ BOX <br />TO INDICATE O CORPORATION [ INDIVIDUAL = PARTNERSHIP LOCAL -AGENCY Q COUNTY -AGENCY 0 STATE -AGENCY 0 FEDERAL -AGENCY <br />DISTRICTS <br />TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR/ <br />IF INDIAN <br />1# OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />5 OTHER <br />ESE <br />LANDS <br />3 <br />3 FARM 4 PROCESSOR a <br />ORTR ST <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) <br />PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) 800-272-6349 <br />Issacson, Ed <br />209-462-1617 <br />Arco Maintenance <br />NIGUTS: NAME (LAST, FIRST) <br />Arco Maintenance <br />PHONE # WITH AREA CODE <br />800-272-6349 <br />NIGHTS: NAME (LAST, FIRST) 800-272-6349 <br />Arco MaintenancePHONE # WITH AREA CODE <br />IL PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />Atlantic Richfield Company <br />CARE OF ADDRESS INFORMATION <br />Environmental Health & Safety Dept. <br />MAILING OR STREET ADDRESS <br />✓ box to indicate INDIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />17315 Studebaker Rd. <br />P] CORPORATION PARTNERSHIP <br />COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE #WITH AREA CODE <br />Cerritos <br />CA <br />90701 <br />310-407-2605 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />'NAME OF OWNER <br />Arco Products Company <br />CARE OF ADDRESS INFORMATION <br />Environmental Health & Safety Dept. <br />MAILING OR STREET ADDRESS <br />✓ box to indicate = INDIVIDUAL <br />LOCAL -AGENCY (] STATE -AGENCY <br />17315 Studebaker Rd • <br />CORPORATION 0 PARTNERSHIP <br />0 COUNTY -AGENCY 0 FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />Cerritos <br />I CA <br />90701 <br />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 0 0 5 0 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box to indicate 1 SELF-INSURED 0 2 GUARANTEE 3 INSURANCE 4 SURETY 80ND <br />5 LETTEROFCREDIT 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 <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. it. =IK I <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 6 SIGNATUR) <br />APPLICANTS TITLE <br />DATE MONTWDAYNEAR <br />Daniel B Goalx4ir <br />Consultant B.C.E.Inc <br />2/1/92 <br />LOCAL AGENCY USE ONLY v <br />COUNTY #� JURISDICTION # FACILITY # <br />`91 � <br />LOCATION CODE6TTIONAL CENSUS TRACT # - OPTIQNA� 0 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 SITE INFORMATION ONLY. <br />FORMA (5-91) / �I / FOR0033A•5 <br />Preparer: Barghausennsulting Engineers Inc.; <br />0-th 4612 Roseville Rd.; Highlands, CA 95660 <br />18215 72nd Ave. South, Kent, WA 98032 <br />