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OSTATE OF CALIFORN WATER RESOURCES CONTROL BOARD zEPOk, '"� <br /> '. CPQ• �Sa <br /> FORM `A': <br /> UNDERGROUND STORAGE TANK PROGRAM " <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE c ori <br /> q�IFO RHP <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT X© 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE hl <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> J <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> BP Oil Company Facility Site 411193 <br /> ADDRESS NEAREST CROSS STREET Boz to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 14 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 3202 West Hammer Lane Ke I ly ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Stockton CA I. <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # #of TANK's <br /> X❑1 GAS STATION ❑3 FARM Ell OTHER TRUST LANDS ar ❑ None AT THIS SITE 3 <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NA(AE(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NA E(LAST,FIRST) PHONE#WITH AREA CODE <br /> Parisi Lou (916) 973-2677 Hollis W. J. (916) 631-6919 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> BP Oil Company <br /> MAILING or STREET ADDRESS y �Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> -CT CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 2969 Prospect Drive, Suite 360 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It,WITH AREA CODE <br /> IR.qnrhn Cnritinva CA 95670 (916) 631-0733 <br /> III. TANK OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> BP Oil Company <br /> MAILING or STREET ADDRESS Box to indicate 1:1 PARTNERSHIP ❑ STATE-AGENCY <br /> 9 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 2868 Prospect Drive Suite 360 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Rancho Cordova ICA 95670 (916) 631-0733 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ III. :1 <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS DATE <br /> W.J. Hollis May 31 , 1989 <br /> LOCAL AGENCY USE LY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID# #of IFILED <br /> m FT9 1 1 1 = <br /> CURRENT LOCAL AG CY FACILITY ID# APPROVED BY NAME PHONE# <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT 8 SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATEYES NOCHECK• PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1JOR MORE TANK PERMIT FORM `B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) <br /> �� DATA PROCESSING COPY <br />