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IT"'IFIED PROGRAM CONSOLIDATED F04 <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(One page per site) Page I of 5 <br />TYPE OF ACTION ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ® 5. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOSED SITE 400. <br />(Check one item only) ❑ 4. AMENDED PERMIT (Specify change) ® 8. TANK REMOVED <br />❑ 6. TEMPORARY SITE CLOSURE <br />1. FACILITY/SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3. <br />FACILITY <br />Waterloo Shell <br />ID# <br />1 <br />NEAREST CROSS STREET 401. <br />FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT* 402 <br />HWY 99 <br />® 1. CORPORATION ❑ 5. COUNTY AGENCY* <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />BUSINESS 1. GAS STATION 3. FARM 0 5. COMMERCIAL 403. <br />TYPE ❑ 2. DISTRIBUTOR [14. PROCESSOR [16. OTHER <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation 405. <br />* If owner of UST is a public agency: name of supervisor of division, section or 406• <br />REMAINING AT SITE <br />or trust lands? <br />office which operates the UST. (This is the contact person for the tank records.) <br />2 <br />❑ Yes ® No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407• <br />PHONE 408. <br />Shell Oil Products C/O Bill Merchant <br />916-684-6125 <br />MAILING OR STREET ADDRESS 409. <br />9141 East Stockton Blvd, Suite 250-321 <br />CITY 410• <br />STATE 411• <br />ZIP CODE 412, <br />Elk Grove 1 <br />CA <br />95747 <br />PROPERTY OWNER TYPE M 1. CORPORATION 0 2. INDIVIDUAL 4. LOCAL AGENCY / DISTRICT 06. STATE AGENCY 413. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414, <br />PHONE 415. <br />Shell Oil Products C/O Bill Merchant <br />925-766-3498 <br />MAILING OR STREET ADDRESS 416. <br />9141 East Stockton Blvd, Suite 250-321 <br />CITY 417. <br />STATE 418. <br />ZIP CODE :119. <br />Elk Grove 1 <br />CA <br />95747 <br />TANK OWNER TYPE 10 1. CORPORATION ❑ 2. INDIVIDUAL 4. LOCAL AGENCY/DISTRICT El 6. STATE AGENCY 420. <br />[13. PARTNERSHIP ❑ 5. COUNTY AGENCY [17. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- 1 0 3 1 9 1 0 1 2 1 6 1 Call 916 322-9669 if questions arise 421. <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) ® 1. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM 422 <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and trailing. <br />Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK OWNER 423. <br />VII. APPLICANT SIGNATURE <br />Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF CANT <br />DATE 424. <br />PHONE 425. <br />OW&%. -r 6;ie_ 14-&L�_ <br />oT b7 a 1 <br />916-631-1300 ext. 19 <br />NAME OF APPLICANT (print) 426• <br />TITLE F APPLICANT 427. <br />Tom Piskor (Agent for Shell Oil Products) <br />Project Manager <br />STATE UST FACILITY NUMBER (Agency use only) 428. <br />1998 UPGRADE CERTIFICATE NUMBER (Agency use only) 429• <br />(See Data Element 1, above. <br />UPCF Hwfwrc-a (1/99) -1/2 http://www.unidocs.org Rev. 02/16/00 <br />