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� y�OF•"'T�, <br /> STATE OF CALIFORNIA• WATER RESOURCES CONTROL BOARD <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �m <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION �� z <br /> �. COMPLETE THIS FORM FOR EACH FACILITY/SITE 10P <br /> MARK ONLY ❑ T NEW PERMIT ❑ 3 RENEWAL PERMIT X❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS — (MUST BE COMPLETED) w <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> BP Oil Com an Facility Site #11192 <br /> ADDRESS NEAREST CROSS STREET ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 1403 County Club Blvd. Pershing 0 El <br /> 1:1COENCY ElFEDERAL-AGENCY <br /> INDIVIDUAL COUNTY-AUNT-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> Stockton CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓Box if INDIAN EPA ID # <br /> RESEVATION1 GAS STATION 3 FARM ❑ 5 OTHER TRUST <br /> ❑ LANDS or ❑ None AT THIS SITE 3 <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 If WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE It WITH AREA CODE <br /> Parisi Lou (916) 973-2677 Hollis, W. J. (916) 631-6919 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> BP Oil Com an <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 2868 Prospect DriveSuite 360 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Rnn(-.hc) Cordova C 1 95670 (916) 631-0733 <br /> III.,TANK OWNER INFORMATION &ADDRESS — (MUST BE COMPLETED) <br /> NAME - CARE OF ADDRESS INFORMATION <br /> BE Oil Company W. J. Hollis Environmental Coordinator <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> L CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE HONE It,WITH AREA CODE <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. ❑ It. ❑ 111. X❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S (PRINTED&SI TMay <br /> ATE <br /> "� W. J. Hollis 31 1989 <br /> LOCAL AGENCY USE O <br /> COUNTY# JURISDICTION# AGENCY# FACILITY <br /> YIID# #of TANKS at SITE <br /> Al <br /> CURRENT LOCAL AGENCY IFACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> LOA/L 0� <br /> PERMIT NUMBER 7PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> YES ❑ NO ❑ <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT TF�ODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEASWR MORE TANK PERMIT FORM `B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(3-2-88) is <br /> DATA PROCESSING COPY <br />