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STATE OF CALIFORNIA <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND ST AGE TANK PERMIT APPLICATION - FORM A 4---a <br /> am <br /> 752444 <br /> MPLETE THIS FORM FOR EACH FACILITYISITE I <br /> ..IAP.KONLY 1 NEW PERMIT 3 RENEWAL PERMIT 5 H 7 PERMANENTLY CLOS Si <br /> ONE ITEM 2 INTERIM PERMIT 4 AMENDED PERMIT a TEMPORARY SITE CLOSURE <br /> I. FACILITY/SIT= INFORMATION Si ADDRESS-(MUST BE COMPLETED) <br /> OBA OR FACILITY NAME NAME OF OPERATOR <br /> BEN HOLT — I-5 SHELL JOHN KENDRICK <br /> ADDRESS NEAREST CROSS STREET PARCEL 0(OPTIONAL) <br /> 3011 WEST BENJAMIN HOLT IN RS T 5 <br /> CITY NAME STATE ZIP CODE SITE PHONE s WITH AREA CODE <br /> STOCKTON��yy Cq 95209 209-477-1703 <br /> TO INDICATE KXCORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL4GENCY Q COUNTYAGENCY Q STATE-AGENCY <br /> g�, DISTRICTS QFEDERAL-AGENCY <br /> TYPE OF BUSINESS �•••.' 1 GAS STATION Q 2 DISTRIBUTOR Q ✓ IF INDIAN IN OF TANKS AT SITE E.P.A. I.D.#(optimal) <br /> 0 3 FARM O 4 PROCESSOR Q 5 OTHER 0 V <br /> TRUSTATION <br /> LAND$ 3 CAD981459613 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME ILAST,FIRST) PHONE#WITH AREA CODE DAY S: NAME(LAST.FIRST) 209-952-6581 <br /> JOHN KENDRICK 209-477-1703 JIM RAY EHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 2 PH2—9 — <br /> NE 4 <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 ✓ box birdiCiN Q INDIVIDUAL Q LOCAL-AGENCY Q STATE-AGENCY <br /> P.O. BOX 4023 KXCORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERALAGEWY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Concord CA 94524 510-676-1414 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAME OF QWNP 9 CARE OF ADDRESS INFORMATION <br /> SHELL OIL COMPANY ENVIRONMENTAL ANALYST <br /> MAILING OR STREET ADDRESS ✓ box W'n Q INDIVIDUAL Q LOCAL AGENCY Q STATEAGENCY <br /> CORPORATION Q PARTNERSHIP Q COUNTYAGENCY Q FEDERAL-AGENCY <br /> Y N <br /> CITAME 409 STATE LP CODE PHONE#WITH AREA CODE <br /> Concord ICA 1 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 lo lo-T7 4 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHODS) USE' <br /> ✓ bm bin , 1 SELF-INSURED 2 GUARANTEE Q 3 INSURANCE Q t SURETY BOND <br /> Q 5 LETTEROFCREOIT Q 6 EXEMPTION Q 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 4ecked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.= I. H.= <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APPLICANTS NAME(P TE0 A SIGNATURE) / APPLICANTS TITLE DATE MONTWDAYNEAR <br /> C�, f l- 3 <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# d4nv JURISDICTION# FACILITY# <br /> �17G!N D E 3a = I. <br /> � �.2 3 <br /> LOCATION COOD�-OPTIONAL CENSU�TR(1CT'?TIONAL SUPVISOR-DIST rE -OPTIONAL <br /> THIS FORM MUST BE ACCOMPANIED BYAATT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE WFOR ATION ONLY. <br /> FORM A(5-91) � / FORa/9' S <br /> //'v 1 �' , -I <br /> �^/_'/ <br /> t� �A/ V ' <br />