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UN =D PROGRAM CONSOLIDATED F M <br /> UNDERGROUND STORAGE TANKS - FACILITY OCT 0 3 202 TANKS <br /> (one page per site) <br /> TYPE OF ACTION F 1.NEW SITE PERMIT X 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- F 7 PERMANENTLY CLOSED SITE <br /> (Check one item only) F 2.NEW OPERATOR local use onl F 8 TANK REMOVED 400 <br /> F 4 AMENDED PERMIT Y) <br /> F 6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 <br /> Marigold Shell, Hung Tran <br /> 6131 Pacific Ave., Stockton, CA 95207 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE h 4 LOCAL AGENCY/DISTRICT- <br /> Porter Ave X 1. CORPORATION F 5. COUNTYAGENCY• <br /> BUSINESS TYPE F 2. INDIVIDUAL F 6. STATE AGENCY' <br /> X 1.GAS STATION F 3.FARM F 5 COMMERCIAL f 3. PARTNERSHIP F 7. FEDERAL AGENCY a02 <br /> F 2.DISTRIBUTOR F 4.PROCESSOR F 6.OTHER <br /> 403 <br /> TOTAL NUMBER OF TANKSIs facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE trustlands? division,section or office which operates the UST <br /> (This is the contact person for the tank records.) <br /> 404 3 F Yes X No 405 406 <br /> Il.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> SHELL OIL PRODUCTS US C/O Bruce T. Marubashi, H,S&E Analyst 1925-766-3498 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. BOX 8509 <br /> CITY 410 STATE 411 FZIP CODE 412 <br /> SAN JOSE CA 95155 <br /> PROPERTY OWNER TYPE F 2. INDIVIDUAL F 4. LOCAL AGENCY I DISTRICT F 6. STATE AGENCY 413 <br /> X 1. CORPORATION f 3. PARTNERSHIP F 5. COUNTY AGENCY F 7 FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> SAME AS II <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE F 2 INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 420 <br /> r 1. CORPORATION r 3 PARTNERSHIP F5 COUNTY AGENCY F 7. FEDERAL AGENCY <br /> TY(TK)HQ 7F <br /> 4 0 3 1 9 0 2 6 1 Call (916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) X 1. SELF-INSURED F 4. SURETY BOND F 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r 5. LETTER OF CREDIT F 8. STATE FUND&CFO LETTER r 99. OTHER: <br /> F 3. INSURANCE F 6. EXEMPTION F 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing X 1 FACILITY r 2 PROPERTY OWNER r 3. TANK OWNER 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> VII ii ICANI SIGNAII IRE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIG NATU OF APPLICANT L DATE 424 1 PHONE <br /> 9/24/02 925-766-3498 425 <br /> NAME OF APPLICANT(print) TITLE OF APPLICANT 427 <br /> BRUCE T. MARUBASHI for Shell Oil Products US 426 H,S&E Analyst <br /> STATE UST FACILITY NUMBER(Forlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />