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�youR es STATE OF CALIFORNIA r a cO p STATE WATER RESOURCES CONTROL BOARD a = UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A :�� 01 COMPLETE THIS FORM FOR EACH FACILITY/SITE 752435 c1ARK ONLY 0 1 NEW PERMIT 0 3 RENEWAL PERMIT X[f] 5 CHANGE OF INFORMATION a 7 PERMANENTLY C ONE ITEM El 2 INTERIM PERMIT 0 4 AMENDED PERMIT [:] 6 TEMPORARY SITE CLOSURE 1. FkCILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR COUNTRY CLUB SHELL CRAIG FURGISON ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 2575 TRY CLUB PLYMOUTH CITY NAME STATE ZIP CODE Sib P O # TH DE STOCKTON CA 95204 4 —® � TOINDIC TE XX CORPORATION I7 INDIVIDUAL = PARTNERSHIP (] LOCAL-AGENCY 0 COUNTY-AGENCY STATE-AGENCY 0 FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ✓ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) VATION 3 FARM 4 PROCESSOR = 5 OTHER ORTRUSESET LANDS 4 CAD981460454 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 209-943-3633 STEVEGRIFFEN 209-948-0574 CRAIG FURGISON NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 209-9t7-5352 SON II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION SHELL OIL COMPANY ENVIRONMENTAL ANALYST MAILING OR STREET ADDRESS ✓ box b indicate 0 INDIVIDUAL (] LOCAL-AGENCY 0 STATE-AGENCY 4023 XX CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH A C D Concord CA 94524 510-610—� �14 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION ,qHET.T. OIL COMPANY ENVIRONMENTAL ANALYST MAILING OR STREET ADDRESS ✓ box to indicate INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY JtX CORPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERAL-AGENCY CI N STATE ZIP CODE PHONE#WITH AREA CODE Concord ICA 94524 510-676-1414 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 4 4 - 0 10 10 10 7 4 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USEr,, ✓ box to indicate 1 SELF-INSURED Ej]2 GUARANTEE 0 3 INSURANCE 4 SURETY BOND D 5 LETTER OF CREDIT =6 EXEMPTION 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II t checked. F ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.El II. III.D THIS FORM HAS BEE PLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT LICANT' AME(PRINT IGNATURE) APPLICANT'S TITLE DATE MON DAY/YEAR Y� LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# 5� 2S o LOCATIONefq OPTIONAL CENSUS TF CTt-OPTICZyAI SUPVISOR-DISTRICT CODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)101 R MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATI�FVOO;3A-5 FORM A(5-91)