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• • bo.UA e <br /> C <br /> STATE OF CALIFORNIA hpP cO� <br /> STATE WATER RESOURCES CONTROL BOARD WQ <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A a o <br /> o <br /> •C•I IfOR N.� <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F—] 1 NEW PERMIT 0 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> ARCO AM PM Facility 5450 Edward A Isaacson <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1617 W. Fremont I-5 135-11-15 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> Stockton CA 95203 209 462-1617 <br /> ✓ BOX <br /> TO INDICATE CORPORATION INDIVIDUAL 0 PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ® 1 GAS STATION a 2 DISTRIBUTOR ✓ IF INDIAN 1#OF TANKS AT SITE I E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS 3 CAL 921724574 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> Isaacson Edward 209 462-1617 Duty Manager (2 - <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> ARCO Maintenance 272-6349 AR Maintenance (8 — <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> ARCO Products Environ. Health & Safety <br /> MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> P.O. Box 6038 CX CORPORATION PARTNERSHIP COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Artesia CA 90702-6038 (714) 670-5404 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ARCO Products Company Environ. Health & Safety <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY 0 STATE-AGENCY <br /> P.O. Box 6038 EM CORPORATION PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Artesia I CA 90702-6038 (714) 670-5404 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - �0 o I ol <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate EX 1 SELF-INSURED 2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND <br /> O 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: I.D II.0 III. <br /> >S <br /> H FORM HAS BEEN LETED UNDE PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLI - NAME(PRINTED APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> —� Project Architect <br /> CAL AGENCY USE ONLY Thomas Schoenstein - Tait & Associates <br /> COUNTY# JURISDICTION# FACILITY#,ff34,ff6 <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 INFO ATION ONLY. <br /> FORM A(5-91) FOR0033A-5 <br />