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STATE OF CALIFORNIA *400 t <br /> STATE WATER RESOURCES CONTROL BOARD s <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION- FORM A <br /> • f,: o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 752444 <br /> LIARK ONLY ❑ t NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED S <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 /> BEN HOLT — I-5 SHELL JOHN KENDRICK <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 3011 WEST BENJAMIN HOLT INTERSTATE 5 <br /> CITY NAMESTATE ZIP CODE SITE PHONE 0 WITH AREA CODE <br /> STOCKTON Cq 95209 209-477-1703 <br /> TOINDICCATE XICORPORATION L-1 INDIVIDUAL O PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INATION DIAN #OF TANKS AT SITE E.P.A. 1.D.S(Optimal) <br /> 3 FARM 4 PROCESSOR [_] 5 OTHER ORRTRUSTVLANDS 3 CAD981459613 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE PWITH AREA CODE DAYS: NAME(LAST.FIRST) 209-952-6581 <br /> JOHN KENDRICK 209-477-1703 JIM RAY <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 2 <br /> IL PROPERTY OWNER INFORMATION• MUST BE COMPLETED <br /> NAME CARE OF ADDRESS INFORMATION <br /> SHELL OIL COMPANY ENVIRONMENTAL ANALYST <br /> MAILING OR STREET ADDRESS ✓boa bidkals 0 INDIVIDUAL [::] LOCAL-AGENCY E::] STATE AGENCY <br /> P.O. BOX 4023 XXCORPORATION 0 PARTNERSHIP E�j COUNTY-AGENCY 0 FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE 4 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 /> SHELL OIL COMPANY ENVIRONMENTAL ANALYST <br /> MAILING OR STREET ADDRESS ✓boa blatlkala 0 INDIVIDUAL 0 LOCAL-AGENCY O STATE AGENCY <br /> Box 4093 ij�j CORPORATION = PARTNERSHIP E:3 COUNTY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#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 /> ✓ boa biMkare I SELF INSURED 2 GUARANTEE Q 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 I or II' checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ I.IllIII.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> D&SIGNA E) / APPLICANTS TITLE DATE MONTWDAYNFAR <br /> APPLICANTS NAME(P TE <br /> LOCAL AGENCY USE ONLY 19 <br /> COUNTY# ftyYW _ JURISDICTION# FACILITY# <br /> LOCATION O/ -OPTIONAL 7ENSUnCTf gTIONAL SUPVISOR-DIST$'�T I* -OPTIONAL Ury <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) FOR0033A5 <br />