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ELE <br /> V <br /> E <br /> STATE OF CALIFORNIA WATER RESOURCES CONTROL" <br /> FORM 'A'-. Iel .gym ` <br /> SITE FACILITY/SITE, I /or I r <br /> COMPLETE THIS FORM FOR EACFACILITY/SITE PERMIT/SERVICE °"OFo '" <br /> [:ARK ONLY ® ' NEW PERMIT ® 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ® 7 PER TLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME &r(7 CARE OF ADDRESS INFORMATION <br /> Shell <br /> ADDRESS 7- J✓ NEAREST CROSS STREET Box indicate ❑'PARTNERSHIP ❑ STATE-AGM <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> G nt Line Road/I-205 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> CA 95376 <br /> TYPE OF BUSINESS: ❑2 DISTRIBUTOR ®4 PROCESSOR ✓Box If INDIAN EPA ID # <br /> RESERVATION or #of TANK's <br /> 10 1 GAS STATION E]3 FARM ❑5 OTHER TRUST LANDS ❑ , lATTHIssffE Four <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> Newsome, Ray 415-676-1414 x123 <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> 11. PROPERTY OWNERINFORMATION -(MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Shell Oil Company <br /> MAILING or STREET ADDRESS Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 1390 W? 1 low Pass Road #900 ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE` ZIP CODE PHONE#,WITH AREA CODE <br /> Conc rd CA 94520 415-676-1414 <br /> 111. TANK OWNER INFORMATION &ADDRESS (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> Shell Oil Company <br /> MAILING or STREET ADDRESS1t�✓Box to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> 1390 Willow Pass Raod #900 }IwCORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> LL11 INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> Concord CA 94520 415- 576-1414 <br /> I . LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)IIOX INDICATING WHICH ABOVE ARE SHOULD BE USEDFOR LEGAL NOTIFICATION AND BILLING:. I. ❑ [I. K] 111. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USEL <br /> COUNTY# JURISDICTION# AGENCY FACILITY ID# #of TINKE <br /> L �l d �d <br /> CURRENT LOCAL AGENCY FACILITY # APPROVED BY NAME PHONE#W <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRI T CODE BUSINESS PLAN FILED DATE FI <br /> YES NO <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# <br /> THIS FORM MUST BE ACCO IED BYT ST(1)OR MORE T 'B'AppLicAmmst UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) 1 A OCESSING COPY 2 LOCAL AGENCYCO* FILE COPY <br /> x <br />