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STATE OF CALIFO A WATER RESOURCES CON OL BOARD y�� lV FX . �f FORM `A': UNDERGROUND STORAGE TANK PROGRAM SST FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ f NEW PERMIT ❑ 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED I$ TE ONE ITEM F-12 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE 9X 1. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) FACILITY/SITE NAME CARE OF ADDRESS INFORMATION BP Oil Company CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS P Oil Company 2868 Prospect Drive Suite 360 CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ADD ESS PHONE #, WITH AREA CODE Rancho Cordova NEAREST CROSS STREET Boz to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY I 1 95670 916 631-0733 CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY East Hammer Lane FEE CODE 14,qmmpr & West SWC ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE SITE PHONE #, WITH AREA CODE CA TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ 4 PROCESSOR ✓ Box if INDIAN EPA ID # ® 1 GAS STATION ❑ 3 FARM ❑ 5 OTHER RESERVATION or TRUST LANDS ❑ None # of TANK's AT THIS SITE 4 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) DAYS: NAME (LAST, FIRST) P.qri.qi_ PHONE # WITH AREA CODE -6915 DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE It WITH AREA CODE NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) '-DtvS-(P%t/'L NAME CARE OF ADDRESS INFORMATION BP Oil Company FACILITY ID # # of TANKS at SITE 0 o1,-2�o o� MAILING or STREET ADDRESS ✓ Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY 2868 Prospect Drive Suite 360 CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE Rancho Cordova 1 1 95670 1 (916) 631-0733 III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION BP Oil Company FACILITY ID # # of TANKS at SITE 0 o1,-2�o o� MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE -AGENCY APPROVED BY NAME PHONE # WITH AREA CODE CORPORATION ❑ LOCAL -AGENCY ❑ FEDERAL -AGENCY 2868 Prospect Drive Suite 360 ❑ INDIVIDUAL ❑ COUNTY -AGENCY CITY NAME STATE ZIP CODE PHONE #, WITH AREA CODE Rancho Cordova 1 SUPERVISOR -DISTRICT CODE a..., 1 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. ❑ if. 111. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME (PRI ED 6 SIGNATUFi DATE W. J. Hollis May 31, 1989 LOCAL AGENCY USE ONLY THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA (3-2-88) DATA PROCESSING COPY JURISDICTION # AGENCY # FACILITY ID # # of TANKS at SITE 0 o1,-2�o o� AGENCY FACILITY ID # FPERMITNUMBER APPROVED BY NAME PHONE # WITH AREA CODE PERMIT APPROVAL DATE PERMIT EXPIRATION DATE If CENSUSTRACT# It SUPERVISOR -DISTRICT CODE a..., BUSINESS PLAN FILED YES NO DATE FILED PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT # BY: THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE TANK PERMIT FORM 'B' APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORMA (3-2-88) DATA PROCESSING COPY