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STATF,O F CALIFORNIA I*, WATER RESOURCES CONTROL EORD <br /> FORM `A': UNDERGROUND STORAGE TANK PROGRAM <br /> SITE FACILITY/SITE, INFORMATION PERMIT APPLICATION <br /> QIl/pRN�r <br /> AiCOMPLETE THIS FOR OR E FACILITY/SITE <br /> MARC ONLY NEW PERMIT ❑3 RENEWAL PERM E OF INFORMATION ❑7 PERNWiENiLY Cl OSED SITE <br /> ONE ITEM ❑2 INTERIM PERMIT 4.AMENDED PERM 6 TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION&ADDRESS—(MUST BE COMPLETED) <br /> FACN.ITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> Exxon RAS # 7-3''LQl% <br /> ADDRESS NEAREST CROSS STREET ✓8abidTC ❑ PMFMMWLWA449 ❑ SteiE•K4W <br /> C �\v 0 *aiPl)RQIaa ❑ LQGI 4&`IY ❑ uu�selcx <br /> ❑ INavD1uL ❑ counr-ACE►xx <br /> CRY NAME STATE ZIP CODE SITE PHON N.WITH AREA CODE <br /> CA <br /> EPA ID N <br /> TYPE OF BtJ51NESS: [--12 DIS111I&JTOR E]t.PROCESSOR ✓8oX M INDIAN B o/TANK'N <br /> QX 1 GASSTAHM [:]3 FARM ❑S OTFER �T LANNDS TION« 1:1AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE N WITH AREA CODE <br /> illasenor, Ernie 415-246-8786 <br /> NIGI,M. NA (LAST.FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(U1ST.FIRST) PHONE N WRH AREA CODE <br /> Exxon CMC 1-800-992-3647 Exxon CMC 1-800-992-3647 <br /> 11. PROPERTY OWNER INFORMATION&ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Exxon Co . , USA <br /> MAILING a STREET ADDRESS ✓ to indicate ❑ PARTNERSHIP ❑ STATE AGENCY <br /> 4550 D a c o ma, 3rd F 1 . ❑ INDIPOftAT10N ❑ LOCAL-AGENCY ❑ FEDERAL AGENCY <br /> VIDUAL ❑ COUNTY-AGENCY <br /> CRY NAME STATE ZIP CODE PHONE N.WITH AREA CODE <br /> Houston TX 77092 1-800-992-3647 <br /> 111. TANK OWNER INFORMATION &ADDRESS—(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Exxon Co . , USA <br /> AILING or STREET ADORfS� ✓Boz to indicate ClPARTNERSHIP ❑ STATE-AGENCY <br /> M <br /> 4550 5 D a E o ma 3rd T 1 . (W CORPORATION [ILOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 7 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATEZIP CODE PHONE N.WITH AREA CODE <br /> Houston TX 77092 1-800-992-3647 <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADORE"SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ IL [-I 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF pERIhRYZAT TO HE BEST OF MY KNOWLEDE.l TRUE AND CORRECT. <br /> APPLICANT'S 40ac Am MUTHORE) GATE <br /> J.G.T. ANALYST A, t <br /> LOCAL AGENCY USE ONLY <br /> F'URRENT <br /> JURISDICTION N AGENCY N FACILITY ID N N of TANKS at SITE <br /> L <br /> AGENCY FACILITY ID N APPROVED BY NAME PHONE N WITH AREA CODE <br /> X51 N 7 <br /> PERMIT NUMBER - PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION'('DE CENSUS TRACT N SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FI V- 9�i) —Z 7 <-i�j�1 Z YESF] NO n CHECK N PERMIT AMOUNT �(J/ SURCHARGELAMOUNT FEE CODE RECEIPT N B . <br /> THIS FORM MUST RE ACCOMPANIED BY AT LEAST(i)OR MORE TANK PERINT FORM`B'APPUCATION(S),UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2.88) 1 "DATA PROCESSING COPY 2 LOCAL AGENCY COPY FILE COPY 1 <br /> d--� - <br />