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STATE OF CALIFORNIA v <br /> s <br /> STATE WATER RESOURCES CONTROL BOARDC'zi <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> COMPLETE THIS FORM FOR EACH FACILRYISITE <br /> 752404 <br /> GiIARK ONLY 1 NEW PERMIT O 3 RENEWAL PERMIT ® 5 CHANGE OF INFORMATION 0 7 PERMANENTLY ED E <br /> ONE ITEM 2 INTERIM PERMIT 0 4 AMENDED PERMIT 0 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION& ADDRESS-(MUST BE COMPLETED) <br /> DBAOR FACILITY NAME NAME OF OPERATOR - <br /> AIRPORT SHELL NICK GOYAL <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 1313 EAST CHARTER WAY WAY <br /> CITY NAME STATE ZIP CODE SITE PHONE N WITH AREA CODE <br /> STOCKTON CA 95205 209-948-4315 <br /> TOINgC TE UMORPORATION 0 INDIVIDUAL O PARTNERSHIP 0 LOCAL-AGENCY 0 COUNTY-AGENCY O STATE-AGENCY FEDERALAGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION = 2 DISTRIBUTOR O ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.N(optional) <br /> RESERVATION <br /> E 3 FARM Q 4 PROCESSOR 0 5 OTHER OR TRUST LANDS 3 NA <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST,FIRST) 510-293-9150 <br /> MANOJ MAHAGAM 209-466-1901 1KRIS GOYAL PHONE a WITH AREA COOP _ <br /> NIGHTS: NAME(LAST,FIRST) PHONE WITH AREA CODE NIGHTS' NAME(LAST,FIRST) <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> SHELL OIL COMPANY ENVIRONMENTAL ANALYST <br /> MAILING OR STREET ADDRESS ✓ Wa Wlndicaw 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE AGENCY <br /> P.O. Box 4023 CORPORATION O PARTNERSHIP D COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N WITH AREA CODE <br /> Concord CA 94524 510-676-1414 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> qHFT-T, OIL COMPANY ENVIRONMENTAL ANALYST <br /> MAILING OR STREET ADDRESS ✓OWblad"w 0 INDIVIDUAL O LOCAL-AGENCY 0 STATE-AGENCY <br /> RPORATION 0 PARTNERSHIP COUNTY-AGENCY 0 FEDERALAGENCY <br /> CI A STATE ZIPC <br /> DOE PHONE N WITH AREA CODE <br /> Concord CA 94524 510-676-1414 <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 4 4 0 0 0 0 7 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED <br /> ✓ has blmkm ISELFINSURED 0 2 GUARANTEE 0 3 INSURANCE 0 4 SURETY BOND <br /> D 5 LETTER OF CREDIT 0 6 EXEMPTION O N OTHER <br /> VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box 1 or II is checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: 1.0 it.O III. <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APP LICA TS NAME(PRINTEDB SIO NAE) AP ANTS TITLE DATE MONTH/DAYNEAR <br /> re Sl cf Qt 7 Jn�i <br /> CAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# iff'k-A 14 <br /> LOCATION CODE -OPTIONAL CENSUS TRACT* -OPTIONAL SUPVISOR-DIST CODE -OPT/ONAL <br /> THIS FOAM MUST BE ACCOMPANIED BY.AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INF ATIO NLY. <br /> FORM A(5-91) FORM A-5 <br />