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SOUR <br />e STATE OF CALIFORNIA i Pe - roti <br />STATE WATER RESOURCES CONTROL BOARD w �, <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />a <br />7 R °•t •onN`� <br />I <br />NAME OF OPERATOR <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE <br />WILLIAM NORBY <br />:)ARK ONLY <br />F7 1 NEW PERMIT <br />3 RENEWAL PERMIT Cfp 5 CHANGE OF INFORMATION ❑ <br />7 PERMANENTLY CLOSED SIT <br />ONE ITEM <br />2 INTERIM PERMIT <br />}0 <br />y IXI 4 AMENDED PERMIT a 6 TEMPORARY SITE CLOSURE <br />0 <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 />PARCEL # (OPTIONAL) <br />4315 WATERLOO ROAD <br />PICCOLI ROAD <br />STATE <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />STOCKTON <br />CA <br />195205 <br />209-931-3674 <br />NTE CORPORATION 0 INDIVIDUAL 0 PARTNERSHIP Q LOCAL -AGENCY Q COUNTY -AGENCY STATE -AGENCY FEDERAL -AGENCY <br />T DIC <br />DISTRICTS <br />TYPE OF BUSINESS " 1 GAS STATION 0 2 DISTRIBUTORQ <br />✓ IF INDIAN <br /># OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />3 FARM Q 4 PROCESSOR = 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />4 <br />NA <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY) - optional <br />DAYS: NAME (LAST, FIRST) PHONE# WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) 209-931-3674 <br />WILLIAM NORBY 209-931-3674 <br />IRMA SALMERON PHM F <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) <br />WILLIAM NORBY 7nq—i6Q-9.7s2 <br />209-547-16655 <br />TRMA SAT.MF.RQN PHONE # WITH AREA CODE <br />II. PROPERTY OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME <br />CARE OF ADDRESS INFORMATION <br />SHELL OIL COMPANY <br />ENVIRONMENTAL ANALYST <br />MAILING OR STREET ADDRESS <br />✓ box to indicate 0 INDIVIDUAL = LOCAL -AGENCY STATE -AGENCY <br />P.O. BOX 4023 <br />KrORPORATION = PARTNERSHIP = COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />Concord <br />CA <br />94524 <br />510-676-1414 <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />SHELL OIL COMPANY <br />CARE OF ADDRESS INFORMATION <br />ENVIRONMENTAL ANALYST <br />MAILING OR STREET ADDRESS <br />✓ box toindicate INDIVIDUAL <br />Q LOCAL -AGENCY STATE -AGENCY <br />P-0 'Rox 4023 <br />ORPORATION PARTNERSHIP <br />Q COUNTY -AGENCY Q FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />PHONE #WITH AREA CODE <br />Concord <br />CA <br />94524 <br />71510-676-1414 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 323-9555 if questions arise. <br />TY (TK) HQ F474 - 010 10 10 7 4 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) - IDENTIFY THE METHOD(S) USED <br />✓ box to Indicate 1 SELF-INSURED 0 2 GUARANTEE Q 3 INSURANCE 4 SURETY BOND <br />O 5 LETTER OF CREDIT Q 6 EXEMPTION 0 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 />CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I. ❑ II. F-1 III. ❑ <br />THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />PLIC NT' NA E PRINTED &SIGN T RE APPLICANTS TITLE DATE EAR <br />All <br />L CAL A ENCY USE <br />COUNTY # JURISDICTION # FACILITY # <br />LOCATION CODE -OPTIONAL (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 SITE INFORMATION ONLY, <br />FORM A (5-91) FOR0033A-5 <br />�3-a-- 73 <br />