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0;�..'H f STATE OF CALIFORNIA WATER RESOURCES CONTROCOA D FORM 'A': UNDERGROUND STORAGE TANK PROGRAM no SITE FACILITY/SITE INFORMATION and/or PERMIT APPLICATION 7. COMPLETE THIS FORM FOR EACH FACILITY/SITE gOFORN P MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT © 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE N ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE qq all, r I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) # FACILITY/SITE NAME CARE OF ADDRESS INFORMATION BP Oil Company Facility Site #11195 ADDRESS NEAREST CROSS STREET ✓Boxloindicale ❑ PARTNERSHIP ElSTATE-AGENCY ff 1:1 LOCAL-AGENCY 16500 Louise 1-5 ❑ NDIVIDUALIDN El COUNTY-AGENCY ❑ FEDERAL-AGENCY CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE CA TYPE OF BUSINESS: F—] 2 DISTRIBUTOR F_�4 PROCESSOR ✓Box if INDIAN EPA ID a NKs RESERVATION or #of T IS SI ❑X 1 GAS STATION E] 3 FARM E]5 OTHER TRUST LANDS ❑ None AT THIS SITE 4 EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS: NAME(LAST,FIRST) PHONE It WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE Parisi Lou (916) 631-6915 Hollis, W. J. (916) 631-6919 NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE t7 WITH AREA CODE Parisi, Lou 916) 973-2677 Hollis W. J. (916) ttt--&9 9-- 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION BP Oil Com any yLy-co00o 3 MAILING or STREET ADDRESS Box Io indicate 11 PARTNERSHIP ElSTATE-AGENCY K CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 2868 Prospect Drive Suite 360 ❑ INDIVIDUAL Cl COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE Rancho Cordova CA 95670 (916) 631-0733 III. TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION BP Oil Company W. J. Hollis Environmental Coordinator MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY IN CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY 2868 Prospect Drive, Suite 360 ❑ INDIVIDUAL ❑ COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE A 95670 (916) 631-0733 IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ II. El m. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT -17 APPLICANT'S NA (PRINTED eSl U DATE May 31 , 1989 LOCAL AGENCY USE ON FPERMITNUMBER JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE EY] / sld I I 1 �/ l AGENCY FACILITY ID# E PHONE#WITH AREA CODE s 6 PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CENSUSTRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILE,,Dyy �)27 326 YES ❑ NO lO !O O 7PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BYc THIS FORM MUST BE ACCOMPANIED BY AT LEASTR MORE TANK PERMIT FORM 'B'APPLICATION(S),UNTHIS IS A CHANGE OF SITE INFORMATION ONLY. ` FORM A ) /\ DATA PROCESSING COPY