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/STATE OF CA4IFORNIA WATER RESOURCES CONTROL BOARD FORM 'A': JA UNDERGROUND STORAGE TANK PROGRAM l 0 SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION - /1 COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT X❑5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE Py ONE ITEM ❑2 INTERIM PERMIT ❑4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION 81 ADDRESS— (MUST BE COMPLETED) / w FACILITY/SITE NAME CARE OF ADDRESS INFORMATION BP Oil Company Facility Site #1119.2 ADDRESS NEAREST CROSS STREET ✓Bar b mchm e ❑ PARTNEF&W Cl STATE-AGENCY 1403 Country Club Blvd. Pershing ® CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY ❑ INDMDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE Stockton CA TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑4 PROCESSOR ✓Box if INDIAN EPA 10 # ESEATION® of TANK 1 GAS STATION ❑3 FARM 5 OTHER TRUST LANDS of El None IATTHIS SITE 3 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE I Hollis, W. J. 916 631-6919 NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE I NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Parisi Lou (916) 973-2677 Hollis W. J. (916) 631-6919 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION P Oil Company MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 2868 Prospect Drive, Suite 360 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE Rancho Cordova CA 95670 (9 1 6) 631-0731 111. TANK OWNER INFORMATION 8t ADDRESS — (MUST BE COMPLETED) t NAME CARE OF ADDRESS INFORMATION t RP Oil Company W. J. Hollis Environmental Coordinator MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP 11STATE-AGENCY0 CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY Suite 160 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE HONE#,WITH AREA CODE CA 9567n I, 65) 631-0231 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. 11. 0 ill. KI THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S (PRINTED&SI DATE W. J. Hollis May I LOCAL AGENCY USE Off 7AGENCY JURISDICTION# AGENCY# FACILITY ID# #of TANKS of SITE 1 1CURRENT LOCAL FACILITY ID# APPROVED BY NAME PHONE 0 WITH AREA CODE �_ D3 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE LOCATION CODE CENSUS TRACT 0 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED YES NO ❑ I CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: I THIS FORM MUST BE ACCOMPANIED BY AT LEAST 11)P-'40RE TANK PERMIT FORM 'B'APPLICATION(S), UNLEF 'IS IS A CHANGE OF SITE INFORMATION ONLY. ORM A(3-2-88) 1�,V/ DATA PROCESSING COPY �`J