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STAT t7F -►L` lt-6 NI� WATER RESOURCES CONTROL BOARD <br /> MAY 2 1 1PI70 <br /> FORM 'A'N_+ m <br /> SIIVIRONMEf T H UNPERGROUND STORAGE TANK PROGRAM n <br /> it <br /> PERM T/k �u TE, INFORMATION and/or PERMIT APPLICATION ; <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ I 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. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> T A SHELL 5AW E <br /> ADDRESS }� NE�A(RE�S)TCROSSSTR�EE/T ✓30xc drate ❑ FAIRNEBSHIP ❑ STATE AGENCY <br /> qdC W. 15 E7T"LE �'//9 PI XZ) �T 1/TG�/SAS R IFI NDIVIDUAL ❑ COUNNAGEHLY 13 LOCAL AGENCY � FEGERAL AGENCY <br /> CITY NAME STATE DECODE SITE PHONE H.WITH AREA CODE <br /> LoC)l CA 9Sayo ao9-33S/- os68 <br /> TYPE OF BUSINESS: EPA ID # <br /> ESERVATION2 DISTRIBUTOR 4 PROCESSOR ✓Box if INDIAN <br /> ©I GAS STATION ❑ 3 FARM ❑ 5 OTHER TRUST LANDS o ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> Goluv&)AY I M AE d07- 3_311-0s-66 &ALL06t.W Q /zOTNY doQ-33#/--os&A <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> AUZWAY M1 /56 a07-33Ll-4/s 3 &q aoraW 0020 N Y �U9-Sa3-03o6 <br /> II. PROPERTY OWNER INFORMATION &ADDRESS- (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> SNGGL p ,",D-4, lY SA*e <br /> MAILING or STREET ADDRESS ✓Box to indicate Cl PARTNERSHIP ❑ STATE-AGENCY <br /> PU yva3 CQ'CORPORATION 11LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> 7 V ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> c04Gp'ii Cq 1 9'l/5a) y/s-6�G �4/y <br /> 111. TANK OWNER INFORMATION &ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> S H EGL OIL- 6047p4^IY l'im/1 <br /> MAILING or STREET ADDRESS ✓Box to Indicate ❑ PARTNERSHIP 13 STATE-AGENCY <br /> P.C. / 1/0 3 El NDIVIDUALION Cl COUNT AGENCY IPORATD LOCAL-AGENCY 171 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE p,WITH AREA CODE <br /> til co2� <br /> CA 9111 7lO- /c//// <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ I. III.❑ <br /> THIS FORM HAS BEEN COMPWT,JFO UND _74ALTY OF PE RY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S I DBSI GATE <br /> LOCAL AGE ONLY <br /> COUNTY# JURISDICTION# AGENCY# FACILITY ID If #of TANKS at SITE <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> 0 PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> \/ 3, �2 YES ❑ NO ❑ "1 )�. CI V <br /> CHECK# PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-88) \ <br /> DATA PROCESSING COPY �1 <br />