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' • esoua es <br /> STATF OF CALIFORNIA P c° <br /> STATE WATER RESOURCES CONTROL BOARD a , <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMA <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> 652203 <br /> i1ARK ONLY F—] 1 NEW PERMIT F—] 3 RENEWAL PERMIT � 5 CHANGE OF INFORMATION � 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 0 2 INTERIM PERMIT F_� 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> RIPON SHELL DAVE POSEY <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 341 EAST MAIN STREET HIGHWAY 89 <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> RIPON CA 195366 209-599-4454 <br /> ✓ BOX <br /> TO INDICATE K,CORPORATION 0 INDIVIDUAL PARTNERSHIP LOCAL-AGENCY COUNTY-AGENCY STATE-AGENCY FEDERAL-AGENCY <br /> DISTRICTS <br /> TYPE OF BUSINESS 1 GAS STATION 2 DISTRIBUTOR ,/ IF INDIAN #OF TANKS AT SITE E.P.A. I.D.#(optional) <br /> RESERVATION <br /> 3 FARM 0 4 PROCESSOR = 5 OTHER OR TRUST LANDS 3 NA <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 209-599-5044 <br /> DAVE POSEY 209-599-4454 STEVE PINE PHONE A WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 2A&-5 - 0 <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 indicate 0 INDIVIDUAL LOCAL-AGENCY STATE-AGENCY <br /> P.O. BOX 4023 KXCORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <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 OWNER CARE OF ADDRESS INFORMATION <br /> SHELL OIL COMPANY ENVIRONMENTAL ANALYST <br /> MAILING OR STREET ADDRESS ✓ box to indicate 0 INDIVIDUAL 0 LOCAL-AGENCY 0 STATE-AGENCY <br /> CORPORATION PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE <br /> Concord jCA 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 F4-[4]- 0 1 0 10 10 17 14 1 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USE7? <br /> ✓ box to indicate 1 SELF-INSURED E�l 2 GUARANTEE E::] 3 INSURANCE 0 4 SURETY BOND <br /> O 5 LETTER OF CREDIT =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 ch ked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.D II. III.El <br /> THIS FORM HAS BEEN COMPLETED UNDER P OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> APP T'S NAME(PRINT D SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> V)d CA A,�� I <br /> LOCAL AGENCY USE 0 LY <br /> COUNTY# JURISDICTION# FACILITY# I� I A)S'F_ 3 41 <br /> F-m y 7 <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) FOR0033A-5 <br />