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STATE OF CALIFORNIA 4 ti <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION-FORM A <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY OX I NEW PERMIT 71 3 RENEWAL PERMIT 11 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED, r <br /> ONE ITEM [:] 2 INTERIM PERMIT CD AMENOED PERMIT C:] 6 TEMPORARY SITE CLOSLIRE q C111 <br /> L FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> ORA OR FACILITY NAME NAME OF OPERATOR <br /> ARCO AM/PM Facility No. 6347 Store Manager <br /> ADDRESS NEAREST CROSS Snerr PARCEL s(OPTIONAL) <br /> 2470 Grantline Road Pombo Road <br /> CITY NAME STATE DP CODE SITE PHONE 4 WITH AREA CODE <br /> Tracy CA <br /> we 8ox 10 CORPORATtCN INDIVIDUAL Q PARTNEMiP LCCAL-AGENCY a COUNTY-AGENCY' Q STATE-AGENC'r' (= FEDERAL-AGENCY' <br /> TOINOICATE DISTRICTS <br /> 'I Offer d UST is a pablk agerW.cmVive RA kftwk)g nmm d supervisor of GNWm.somOM1 of oft which opa=$Me UST <br /> TYPE OF BUSINESS T GAS STATION a 2 DISTRIBUTOR d IF INDIAN •OF TANKS AT SITE E P.A 1.D.a(oDrrn9 <br /> RESERVATION <br /> a 3 FARM Q A PROCESSOR Q S 0713ER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE 1I WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE b WITH AREA CODE <br /> ARCO Maintenance 1-800-ARCO-FIX 634 <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITIi AREA CODE NIGHTS; NAME(LAST,FIRST) PHONE s WITH AREA CODE <br /> ARCO Maintenance 1-800-ARCO-FIX <br /> II. PROPERTY OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> ARCO Products Com2any ARCO Environmental Health & Safety <br /> MAILING OR STREET ADDRESS -f box to 05mia Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AMCY <br /> 4 Centerpointe Drive CORPORATION Q PARTNERSHIP . Q COUNTY-404CY Q FEDERAL-AGENCY <br /> CITY NAME STATE "' <br /> CODE PHONE s WITH AREA COOS <br /> La Palma CA 90623 (714) 670-5401 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> ARCO Products Company ARCO Environmental Health & Safety <br /> MAILING OR STREiET ADDRESS -1 box to rd me Q INDIVIDUAL Q LOCOLAGENCY Q STATE-AGENCY <br /> 4 Centerpointe Drive I2CORPORArION 11 PARTNERSHIP p COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE s WITH AREA CODE <br /> La Palma CA 90623 (7 670-5401 <br /> 670-5401 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)322-9669 if questions arise. <br /> TY(TK) HO 4 4- _j 0 10 10 15= <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓box mlru0lcote %R I SELF-INSURED Q 2 GUARANME Q 3 INSURANCE C3+SURETY BONO Q 5 LETTER OF CREDIT C3 6 ExEMFrION O 7 STAMFUNO <br /> Q 8 STATE FUND a CHIEF FINANCIAL oFRCFR LETIER 0 9 STATE FUM?a CCRTIFlCATE OF OEPOSrr p 10 LOCAL covT,MECHANLSY Q x OTHER._ <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and biding will be sent to the tank owner unless box t or 11 is checked. <br /> CHECK ONE BOX INOICATING WHICH ABOVE ADDRESS SHOULD BE.USED FOR LEGAL NOTIFICATIONS AND BILLING: L Q IL IM 111.[7 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND t0 Th E 8ES7 OF MY KNOWLEDGE,IS TRUE ANO CORRECT <br /> TANK OWNER'S N & A TANK OWNER'S TITLE DATE MONTWOAY/YEAR <br /> G ARCO Agent <br /> LOCAL AGENCY USE ONLY <br /> COUNTY$ JURISDICTION x FACILITY a (o <br /> b 1 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR•DISTRICT CODE -OP7 0NAL / <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM S.UNLESS T141S IS A CHANGE OF SITE INFORMATION ONLY. <br /> OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS <br /> FORM A(695) <br /> Z d IAIOJd Hd7Z: 1 L661-60-L <br />