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HEALTH GDpY <br /> STATE OF CALIFORtmit WATER RESOURCES CONTHO BOARD` <br /> FORM `A': UNDERGROUND STORAGE TANK PROGR li" <br /> SITE FACILITY/SITE, INFORMATION and/or PERM I `APPLICCATIO;N <br /> OF it <br /> , • <br /> C 1 <br /> ,, p tt7 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE f ,; ;",� ,; v � 3 � <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT X❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE !V <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> ..r <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> BP Oil Company Facility gitp- #11194 <br /> ADDRESS NEAREST CROSS STREET 11010r4cak ❑ PANTNOW ❑ STATE-AGENCY <br /> 14CORPMTO ❑ LOCAL-AGM ❑ FB1tAA4900 <br /> 9375 Tracy Blvd, rant1ine & McKinl iNGMoK ❑ COUIMAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE N.WITH AREA CODE <br /> Tracey CA <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR F_�4 PROCESSOR I ✓Box d INDIAN EPA ID p <br /> RESERVATION or t of TANK s <br /> ®I GAS STATION 0 3 FARM ❑5 OTHER TRUST LANDS ❑ None AT THIS SITE LF <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE K WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Parisi, Lou (916) 631-6915 Hollis W. J. (916) 631-6919 <br /> NIGHTS: NAME(LAST.FIRST) PHONE 11 WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> W J. 916 69t-*9 '9 <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— ( UST E COMPLETED) `�6S-4�kl'Z--- <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 2968 Prospec Drive, Suil-P 160 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATEZIP CODE PHONE It,WITH AREA CODE <br /> RA1312130 Cardiolza CA 25620 (216) 1- <br /> 111. TANK OWNER IN &ADDRESS—(MUST BE COMPLETED) <br /> NAME ! CARE OF ADDRESS INFORMATION <br /> BP Oil Company r <br /> MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 9 CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 2868 Prospectp Drive Suite 360 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE(t.WITH AREA CODE <br /> Rancho Cordova CA 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: 1. it. [—] III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S (PRINTED DATE <br /> W. J. Hollis May 31 1989 <br /> LOCAL AGENCY USE <br /> COUNTY A JURISDICTION If AGENCY N FACILITY ID X N o1 TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID• APPROVED BY NAME PHONE k WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE , CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO <br /> CHECK N PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT a BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT Fa 'B'APPLICATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORMA(3-2-88) <br /> DATA PROCESSING COPY <br />