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STATE OF CALIFORNIA <br /> 9 <br /> STATE WATER RESOURCES CONTROL BOARD w <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORMANz <br /> A 441608 <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY NEW PERMIT F—] 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM 2 INTERIM PERMIT F-1 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE �Z <br /> I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) <br /> DBA OR FACILITY NAME NAME OF OPERATOR <br /> FREEWAY SHELL DONALD SWIM <br /> ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) <br /> 880 VICTOR ROAD BECKMAN ROAD <br /> CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE <br /> LODI Cq 95240 209-368-3755 <br /> ✓ BOX <br /> TO INDICATE (ICORPORATION 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 /> RESE <br /> 0 3 FARM 4 PROCESSOR = 5 OTHER ORTRUSTVANIDS 5 CAD981460215 <br /> EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional <br /> DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) 209-368-3755 <br /> Donald Swim 209-368-3755 Bud Swim PHOI IF <br /> NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) <br /> 916-686-5872 <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 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> P.O. Box 4023 RXCORPORATION (] 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 INDIVIDUAL 0 LOCAL-AGENCY STATE-AGENCY <br /> 'P Rox 4093 CORPORATION 0 PARTNERSHIP COUNTY-AGENCY FEDERAL-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE It 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 F4-T-4] 0 10 10 10 7 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USEf) <br /> ✓ box to indicate 1 SELF-INSURED 2 GUARANTEE 3 INSURANCE 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 checked. <br /> CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.[:] it.P� III.El <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT <br /> PAPPLI ANT' NAME(PRINTE SIGNATURE) APPLICANTS TITLE DATE MONTH/DAYNEAR <br /> - �"-- <br /> OCALAGENCY USE ONLY <br /> COUNTY# JURISDICTION# FACILITY At $'$' <br /> LOC�ON CODE -OPTIONAL CE SU TRAC OPTIONAL SUPVIDISTRICT CODE -OPTIONAL F <br /> V"?, r <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 />