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'R <br />6�q � <br />STATE OF CAUFORWA <br />STATE WATER RESOURCES CONTROL BOARD S <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A , <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE °'...... <br />MARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT a 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br />ONE REM F-1 2 INTERIM PERMIT 0 4 AMENDED PERMIT D 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR FACILITY NAME <br />NAME OF OPERATOR <br />Waterloo Shell <br />William Norby <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCELIN (OPTIONAL) <br />4315 Waterloo Road <br />Piccoli Road <br />IITY NAME <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />Stocktu <br />CA <br />95205 <br />209-931-3674 <br />I/ Box <br />TO INDICTE dRPORATION Q INDIVIDUAL = PARTNERSHIP LOCAL -AGENCY COUNTY -AGENCY' E::] STATE -AGENCY- 0 FEDERAL -AGENCY' <br />DISTRICTS' <br />If owner of UST Is a public agency, complete the following: name of Supervisor of division, section, or office which operates the UST <br />TYPE OF BUSINESS GAS STATION 0 2 DISTRIBUTORO <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />3 FARM 4 PROCESSOR 0 5 OTHER <br />OR TRUST LANDS <br />2 <br />N/A <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARYI - antinnal <br />DAYS: NVj {LA T, FIRsn Norby <br />Pj?p E j.WITM ffA CODE <br />DAjji�AME (LAST, Ffilieron <br />20fU""WT AREA CODE <br />NIGHTS:(LAST, FIR <br />P111 iam arby <br />PHONE # WITH AREA CODE <br />209-369-2252 <br />NIGHTS: NAME (LAST FIRST) <br />Irma 8almeron <br />H T AREA CODE <br />206WAYR <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME SHELL OIL COMPANY <br />CAI�EIFAP1VgTMg"T"E <br />MAILING OR STREET ADDRESS <br />P.O. BOX 4023 <br />✓ qbox b Indicate 0 INDIVIDUAL <br />LOCAL -AGENCY 0 STATE -AGENCY <br />P.O. BOX 4023 <br />1ORPORATION = PARTNERSHIP <br />Q COUNTY -AGENCY 0 FEDERAL -AGENCY <br />IITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />CONCORD <br />CA <br />94524 <br />510-675-6100 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OFSITYLLROIL COMPANY <br />CAV r I ffI-SS fiff TdplltE <br />MAILING OR STREET ADDRESS <br />✓ box b indicate 0 INDIVIDUAL <br />LOCAL -AGENCY STATE -AGENCY <br />P.O. BOX 4023 <br />ORPORATION = PARTNERSHIP <br />COUNTY -AGENCY FEDERAL -AGENCY <br />CIN NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />CONCORD <br />CA <br />94524 <br />510-675-6100 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HQ M44- - O lip O 4 <br />V. PETROLEUM UST FINANC14 RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ box bindicate ricl SELF-INSURED (] 2 GUARANTEE 71 9 INSURANCE E�:] 4 SURETY BOND <br />5 LETTER OF CREDIT 0 6 EXEMPTION E�j 99 OTHER <br />VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. <br />JUIrl <br />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FORLEGAL NOTIFICATIONS AND BILLING: I. if. III. <br />THIS FORM HAS BEEN COMPLETED UNDER FtNALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />OWNER'S NAME (PRINTED & SIGNED)OWNER'S TITLE f DATE MONTWDAYNEAR <br />Y, j�7t t -t- N �)'P- i*t <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />1 16 <br />LOCATION CODE -OPTIONAL I CENSUS TRACT # - OPTIONAL SUPVISOR - DISTRICT CODE - OPTIONAL <br />THIS FORM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF Sm INFORMAT)ON ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULAMM <br />FORM A (3/113) FOR0033A- (7 <br />