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rfi:�g' •�s-ramFa•,vri'p%°is," �T�d�rT QTR' p, '�1r1wm9"v'1"T.'. F". 5'';vmg�•;w.+,R.+wr. .v <br /> STATE OF CALI FO R N IV WATER RESOURCES CONTR yEP 'T"� <br /> O OARD <br /> FORM `A': . <br /> UNDERGROUND STORAGE TANK PROGRAM =`gy <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION r ZF. . <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITEc I Q <br /> N�IFO RNP <br /> MARK ONLY F—] f NEW PERMIT F—] 3 RENEWAL PERMIT [_X] 5 CHANGE OF INFORMATION ❑]IgLY CLOSED SITE N <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE '� <br /> r <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) W <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> RP Oil Company Encility Site #11194 <br /> ADDRESS NEAREST CROSS STREET Bortoindicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION E3LOCAL-AGENCY 11FEDERAL-AGENCY <br /> 9375 Tracy Blvd. Grantline & McKinl INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> CA �� Zo d' ' S <br /> — <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑4 PROCESSORFREEEORVATION <br /> Bx INDIAN EPA ID #or #of TANK's <br /> 1z 1 GAS STATION [:] 3 FARM ❑ 5 OTHER ST LANDS ❑ None AT THIS SITE LF <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#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#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Hollis, W. J. (916) 69 —fr9" <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) C56S_(04P <br /> NAME CARE OF ADDRESS INFORMATION <br /> BE Oil Compan�z <br /> MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 2868 Prospect Drive, Suit-e 360 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> 95670 16 631-0733 <br /> III. TANK OWNER INFORMATION & ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> BP Oil Company Environmental Coordinator <br /> MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 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 CA 95670 (916) 631-0733 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(t)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ if. ❑ III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF P RJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANTS (PRINTED DATE <br /> W. J. Hollis May 31 1989 <br /> LOCAL AGENCY USE <br /> FPERN <br /> JURISDICTION# AGENCY# FACILITY ID# #of TANKS at SITE <br /> L I l q � <br /> AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> v <br /> PERMIT AP ROVAL DATE PERMIT EXPIRATION DATE <br /> CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED f� <br /> � z-&/ YES ❑ NO ❑ 9�ZZIa <br /> PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY, <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST 1 OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLFSS THIS IS A CHANGE OF SITE INFORMATION ON <br /> FORM A(3-2-88) <br /> � DATA PROCESSING COPY � "•.a• <br /> ( -, l� _� <br />