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STATE OF CALIFORNIA ^r oA <br /> --, STATE WATER RESOURCES CONTROL BOARD <br /> (UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br /> r.­�, —n, ^'-' n COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> NARK ONLY 711 NEW PERMIT ❑ 3 RENEWAL PERMIT X�5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SI <br /> ONE ITEM El INTERIM PERMIT ❑ 4 AMENDED PERMIT E] 6 TEMPORARY SITE CLOSURE O/ <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 99 SHELL XXXXX AUSTIN WATERS <br /> ADDRESS NEAREST CROSS STREET PARCEL (OPTIONAL) <br /> 7700 MORELAND COURT HAMMER <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> STOCKTON CA 95212 209 —957-5398 <br /> ✓ BOXy <br /> TO INDICATE O U CORPORATION INDIVIDUAL = PARTNERSHIP LOCAL-AGENCY 0 COUNTY-AGENCY 0 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 O 4 PROCESSOR = 5 OTHER OR TRUST LANDS 4 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAMELAST,FIRST) <br /> WATERS AUSTIN 209-957-5398 CARROLL , RANDY 209-957-5398 <br /> PHONE A WITH AREA rODF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 209-632-7618 - <br /> 11. 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 LOCAL-AGENCY STATE-AGENCY <br /> P O BOX 4023 (CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 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 OWNfcR CARE OF ADDRESS INFORMATION <br /> SHELL OIL COMPANY <br /> MAILING OR STREET ADDRESS ✓ box to indicateINDIVIDUAL <br /> � (] LOCAL-AGENCY STATE-AGENCY <br /> P 0 BOX 4023 MXCORPORATION 0 PARTNERSHIP (] COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH A A DE <br /> CONCORD CA 94524 510 67 68 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 - O 0 0 0 7 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ box to indicate 1 SELF-INSURED (]2 GUARANTEE 3 INSURANCE 0 4 SURETY BOND <br /> 5 LETTER OF CREDIT (]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.❑ II. III.❑ <br /> THIS FORM H S BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> RIN D&SIGNATURE) APPLICANTS TITLE TE MONTWDAYNEAR <br /> HS&E ANALYST SHELL OIL C1/24/94 <br /> LO AL AGEIVY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> LOCATION CODE -OPTIONAL CENSUS TRACT# -OPTIONAL SUP OR-91STRICT 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 /> �rf lye<a� <br />