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• ; <br /> I ho •• C <br /> STATE OF CALIFORNIA ' ', <br /> STATE WATER RESOURCES CONTROL BOARD ,;�� we a <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FOP9d1�A 1 4 19 ,: > <br /> ENVIRONMENTAL H <br /> COMPLETE THIS FORM FOR EACH FACILITYISITE <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT © 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE <br /> I. FACILITYISITE INFORMATION&ADDRESS.(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> 1asayxAkat}xx Tokay Shell Same <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 402 W. Kettleman d Hutchins <br /> CIT—NAME STATE ZIP CODE SITE PHOlI�(WIM/,pEA CODE <br /> Lodi CA 95240 LUyy 33 // 11�/��22SS <br /> TOIN BO TE l CORPORATION Q INDIVIDUAL ED PARTNERSHIP Q LOCAL-AGENCY COUNTY-AGENCY 0 STATE-AGENCY O FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS ® I GAS STATION ❑ 2 DISTRIBUTOR ❑ RESERVATION <br /> IF INDDIAN #OF TANKS AT SITE E.P.A. I.D.#Nplimal) <br /> O 3 FARM 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: NAME(LAST.FIRST) 209-369-1778 <br /> Wagner, Larry 209-369-1778 Lutz, Robert PHONE A WITH AREA GORE <br /> NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) 209-476-1312 <br /> PHONE#WITH AREA CODE <br /> 209-462-6121 <br /> II. PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> Shell Same <br /> MAILING OR STREET ADDRESS ✓bo,b Indicate INDIVIDUAL O LOCAL-AGENCY D STATE-AGENCY <br /> P. O Box 4023 D�CORPORATION O PARTNERSHIP 0 COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE AREA CODE <br /> Concord CA 94520 510-676-1414 <br /> IIT. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF OWNER CARE OF ADDRESS INFORMATION <br /> MAILING OR STR TAD ✓ ffi Indicate O INDIVIDUAL O LOCAL-AGENCY STATE AGENCY <br /> P. 0. Box 4023 [0 CORPORATION PARTNERSHIP [:7]COUNTY-AGENCY O FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Concord CA 94520 510-676-1414 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. <br /> TY(TK) HQ 44 -L <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED <br /> ✓ bo,blndlW I SELF-INSURED F--12 GUARANTEE L:j 3 INSURANCE 4 SURETY BOND <br /> 5 LETTER OF CREDIT O 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.[y III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAM E(PR INTED&SIGNATURE) APPLICANTS TITLE DATE MONT VDAYNEAR <br /> Jock k—c dr,� � 9 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY# <br /> m nim <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) <br />