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STATE OF CALIFORNIA „ WATER RESOURCES CONTROL BIRD s }a� <br /> FOR!,! '_A: UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION ` > <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMR 6 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT ❑A AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION -..- <br /> Exxon RAS 11 <br /> NEAREST CROSS STREET 0 PNIO9P 0 ST <br /> OO <br /> ADDRESS C�CDRPWTOx 0 LOCkAGD0 ❑ RA[EII <br /> LY <br /> 0 NMDA 0 OXNnJf1C <br /> CRY NAME \ STATE ZIP CODE SITE PHONE 1.WITH AREA CODE <br /> Sloe CA la.520� <br /> TYPE OF BUSINESS: ❑2gS1RBJI0R ❑IPROtOR ✓BaININDIIGNAN EPA IDN FDI TANKL <br /> Q 1 GASSTATDN ❑3 FAN ❑74= <br /> OTHER RTRUST IANOS A ON a ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS NAME(UST.FRTST) <br /> _L PE N WITH AREA CODE DAYS: NAME RAST.FIRST) PHONE N WITH AREA CODE <br /> illasenor , Ernie 415-246-8786 <br /> NIGHTS: NAM T.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(UST.RRST) PRONE N WITH AREA CODE <br /> Exxon CMC 1-800-992-3647 Exxon CMC 1-800-992-3647 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Exxon Co . , USA <br /> MAILING a STREET ADDRESS ✓ •b+IQ O 0 PARTNERSHIP 0 STATE-AGENCY <br /> [�T CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 4550 D a c o ma , 3rd Fl . 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N.WITH AREA CODE <br /> CRY NAME <br /> Houston TX 77092 1-800-992-3647 <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> CARE OF ADDRESS INFORMATION <br /> NAME <br /> Exxon Co . , USA <br /> MAILING a STREET ADDRESS ✓Boa to indcale ClPARTNERSHIP 0 STATE-AGENCY <br /> 3rd 1 . Cil'CORPORATION 0 LOCAL-AGENCY 0 FEDERAL-AGENCY <br /> 4550 D a c o ma <br /> 0 INDIVIDUAL 0 COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> Houston TX 77092 1-800-992-3647 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> 130 <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. N. ❑ 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY TH BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS NABR(PR M®Y�1 GATE <br /> �7 J G t 17791, <br /> LOCAL AGENCY USE ONLY <br /> CN JURISDICTION N AGENCY N FACILITY 10 N F o/TANKS at SITE <br /> OUNTY <br /> CURRENT LOCAL AGENCY FACILITY ID M <br /> APPROVED BY NAME PHONE N WITH AREA CODE <br /> PERMITNUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED <br /> DATE FILED lgj <br /> 23 ' YES NO El z Z <br /> CHECK, PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE <br /> RECEIPT N BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERYR FORM'B�APPIICATI011(S),UNLESS THIS K A CHANGE OF SITE INFORMATION ONL 0- <br /> FORM A(3-2 88) 1 DATA PROCF-SING COPY 2 LOCAL AGENCY COPY 3 FILE COPY 1 <br />