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C ` <br />6pUq � <br />STATE OF CALIFORNIA <br />STATE WATER RESOURCES CONTROL BOARD <br />UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A <br />COMPLETE THIS FORM FOR EACH FACILITY/SITE °4kjpoRo'' <br />MARK ONLY F-1 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 0 7 PERMANENTLY CLOSED SITE <br />ONE ITEM 0 2 INTERIM PERMIT 0 4 AMENDED PERMIT Q 6 TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) <br />DBA OR REEWAY SHELL <br />N`bAfRA�IM <br />SWIM, DONALD 209-368-3755 <br />SWIM, BUD 209-368-3755 <br />ADDRESS <br />NEAREST CROSS STREET <br />PARCEL # (OPTIONAL) <br />880 VICTOR ROAD <br />BECKMAN ROAD <br />P 0 BOX 4023 <br />CITY NAME <br />STATE <br />ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />LODI <br />CA <br />95240 <br />209-368-3755 <br />TO f BOX <br />E�] CORPORATION n INDIVIDUAL ED PARTNERSHIP 0 LOCAL -AGENCY 0 COUNTY-AGENCYSTATE-AGENCY' = FEDERAL -AGENCY' <br />DISTRICTS' <br />If owner of UST Is a public agency, complete the following: name of Supervisor of division, section, or office which operates the UST <br />TYPE OF BUSINESS ® 1 GAS STATION 0 2 DISTRIBUTOR <br />= ✓ IF INDIAN <br />1# OF TANKS AT SITE <br />E. P. A. I. D. # (optional) <br />0 3 FARM 4 PROCESSOR = 5 OTHER <br />RESERVATION <br />OR TRUST LANDS <br />5 <br />EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON fSFCONnARV1. n tInnnl <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />DAYS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />SWIM, DONALD 209-368-3755 <br />SWIM, BUD 209-368-3755 <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />NIGHTS: NAME (LAST, FIRST) PHONE # WITH AREA CODE <br />209-763-5369 <br />916-686-5872 <br />11. PROPERTY OWNER INFORMATION - (MUST RE COMPLFTEDI <br />NAME <br />CARE OF ADDRESS INFORMATION <br />SHELL OIL COMPANY <br />✓ box to indicate = INDIVIDUAL <br />= LOCAL -AGENCY STATE -AGENCY <br />MAILING OR STREET ADDRESS <br />✓ box to Indicate INDIVIDUAL <br />= LOCAL -AGENCY STATE -AGENCY <br />P 0 BOX 4023 <br />f CORPORATION PARTNERSHIP <br />= COUNTY -AGENCY FEDERAL -AGENCY <br />CITY NAME <br />STATE <br />ZIP CODE <br />CA <br />PHONE #WITH AREA DE <br />CONCORD <br />CA <br />94524 <br />510 675-61�$ <br />III. TANK OWNER INFORMATION - (MUST BE COMPLETED) <br />NAME OF OWNER <br />SHELL OIL COMPANY <br />CARE OF ADDRESS INFORMATION <br />MAILING OR STREET ADDRESS <br />✓ box to indicate = INDIVIDUAL <br />= LOCAL -AGENCY STATE -AGENCY <br />P 0 BOX 4023 <br />M CORPORATION 0 PARTNERSHIP <br />= COUNTY -AGENCY (] FEDERAL -AGENCY <br />CIN NAME <br />STATE <br />ZIP CODE <br />PHONE # WITH AREA CODE <br />CONCORD <br />CA <br />1 94524 <br />510 675-6100 <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER - Call (916) 322-9669 if questions arise. <br />TY (TK) HO 4 4- - P 1 01010-111 41 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY - (MUST BE COMPLETED) — IDENTIFY THE METHOD(S) USED <br />✓ <br />box bIndicate Eat SELF-INSURED (] 2 GUARANTEE =1 3 INSURANCE E�:] 4 SURETYBOND <br />= 5 LETTEROFCREDIT 0 6 EXEMPTION E-1 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. 0 A III. 0 <br />THIS FORM HAS�EN COMPL�.gUNDER PENALTY OF PERJURY, AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT <br />D SIG D) <br />OWNE4PN <br />OWNER'S TITLE <br />DATE MONTWDAY/YEAR <br />L <br />L <br />HSOE ANALYST <br />9/12/94 <br />LOCAL AGENCY USE ONLY <br />COUNTY # JURISDICTION # FACILITY # <br />LOCATION CODE -OPTIONAL CENSUS TRACT # -OPTIONAL SUPVISOR -DISTRICT CODE -OPTIONAL <br />THIS FOHM MUST BE ACCOMPANIED BY AT LEAST (1) OR MORE PERMIT APPLICATION - FORM B, UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br />OWNER MUST FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATKINS <br />FORMA (3/93) FOR0043A-R7 <br />