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eeo"aces <br /> STATE OF CALIFORNIA a COs <br /> STATE WATER RESOURCES CONTROL BOARD <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> `• � <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE 752435 <br /> ]"^RK ONLY E7 1 NEW PERMIT � 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED/SITE <br /> ONE ITEM [= 2 INTERIM PERMIT = 4 AMENDED PERMIT = 6 TEMPORARY SITE CLOSURE ®f <br /> I. FkCILITY/SITE INFORMATION&ADDRESS•(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> COUNTRY CLUB SHELL CRAIG FURGISON <br /> ADDRESS I NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 2575 COUNTRY CLUB PLYMOUTH <br /> CITY NAME STATE ZIP CODE S T PON # TH DE <br /> STOCKTON CA 95204 4"�-�a` � <br /> TOINDICATE XX CORPORATION Q INDIVIDUAL Q PARTNERSHIP Q LOCAL-AGENCY Q COUNTY-AGENCY Q STATE-AGENCY Q FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS)M 1 GAS STATION Q 2 DISTRIBUTORRESE F INDIAN <br /> #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> Q 3 FARM 0 4 PROCESSOR Q 5 OTHER OR TRUST LANDS 4 CAD981460454 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST.FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 209-943-3633 <br /> STEVEGRIFFEN 209-948-0574 CRAIG FURGISON PWQFjfz it WITH A13EA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 209-957-5352 <br /> SON PHONE#WITH AREA COnF: <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 to indicateINDIVIDUAL <br /> Q Q LOCAL-AGENCY Q STATE-AGENCY <br /> 12.0. Box 4023 XX CORPORATION- Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WIT A C D <br /> Concord CA 94524 510-dbi-�h14 <br /> III. TANK OWNER INFORMATION-(MUST BE COMPLETED) <br /> NAM OF O'WN'iFa CARE OF ADDRESS INFORMATION <br /> SHELL OIL COMPANY ENVIRONMENTAL ANALYST <br /> MAILING OR STREET ADDRESS ✓ box toindicateINDIVIDUAL <br /> Q Q LOCAL-AGENCY Q STATE-AGENCY <br /> Box 41123 3t�j CORPORATION Q PARTNERSHIP Q COUNTY-AGENCY Q FEDERAL-AGENCY <br /> CI N M STATE ZIP CODE PHONE#WITH AREA CODE <br /> Concord ICA 94524 510-676-1414 <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise, <br /> TY(TK) HO 44 I- 0 10 10 10 17 14 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY•(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USE-_ <br /> ✓ box bindicate 1 SELF-INSURED J 2 GUARANTEE Q 3 INSURANCE 0 4 SURETY BOND <br /> 0 5 LETTER OF CREDIT 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 A checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.C Ii.V. III.a <br /> THIS FORM HAS BEE PLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> LICANT' AME(PRINT IGNATURE) APPLICANTS TITLE DATE MON WDAYNEAR <br /> r� y/ow'k- y sCY <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION;; FACILITY# <br /> r391 �5 <br /> LOCATION OPTIONAL CENSUS TRACT -OPTIC SUPVISOR-DISTRICT CODE -OPTIONAL <br /> i <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION- FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATIO <br /> FORM A(5-91) F 0033A-5 <br />