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Pe50UR �S Cry <br /> STATE OF CALIFORNIA / ,? <br /> + STATE WATER RESOURCES CONTROL BOARD , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A w ° <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY F7 1 NEW PERMIT O 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION a 7 PERMANENTLY CLOSED SIT <br /> ONE ITEM O 2 INTERIM PERMIT 0 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR,FAGINTf WAM�D SHELL NAME OF <br /> ADDRESS 1hV EARESTCROSS STREET PARCEL#(OPTIONAL) <br /> 6131 PACIFIC AVE PORTER AVE <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> STOCKTON CA 95207 209 952-4862 <br /> I/ Box <br /> TOINDICATE E5dXORPORATION F-1 INDIVIDUAL 0 PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ® 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 4 PROCESSOR = 5 OTHER OR TRUST LANDS 3 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) <br /> TRAN, HUNG 209-952-4862 HUYNH, JOHN P — — 2 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 707-558-9324 <br /> 209-473-8205 PHONE#WITH <br /> II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> SHELL OIL COMPANY <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL Q LOCAL-AGENCY STATE-AGENCY <br /> P O BOX 4023 [MGORPORATION PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> CONCORD CA 94524 510 675-6100 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> SHELL OIL CO <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL LOCAL-AGENCY <br /> STATE-AGENCY <br /> PO BOX 4023 ORPORAT10N PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE CODE PHONE#WITH AREA CODE <br /> ZIP <br /> CA 94524 510 675-6100 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - 01 01 01 0� <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate Rticl SELF-INSURED 2 GUARANTEE 3 INSURANCE 4 SURETY BOND <br /> L�] 5 LETTER OF CREDIT 0 6 EXEMPTION 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.F-1 II.[XII III. <br /> THI ORM HAS BEEN CO ETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> dQ <br /> APPLICAN D 8 SIGNATU PPLICANT'S TITLE DATE MONTH/DAY/YEAR <br /> ` RE DS HS&E ANALYST 1/31/95 <br /> CAL AGEN6 USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> 3 �s <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 />