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i -IED PROGRAM CONSOLIDATED FO <br /> ", • <br /> L TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY Apr) <br /> (one page per site) Page of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ .7 RERMANENTLY cLOSEt) 4.A <br /> 'r. <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only d 8.f`ANK R JEbr 1 <br /> ❑&TEMPORARY SITE CLOSURE k6 ry 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# <br /> 99 Shell 1 <br /> 7700 Moreland Court, Stockton CA 95212 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT' <br /> Hammer Lane E 1.CORPORATION ❑ 5.COUNTY AGENCY; <br /> BUSINESS E 1.GAS STATION ❑3.FARM ❑ 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 4 404 ❑ Yes E No 405 406 <br /> ll. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Shell Oil Products US 310-816-2027 <br /> MAILING OR STREET ADDRESS 409 <br /> 20945 S. Wilmington Ave. <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Carson CA 90810 <br /> PROPERTY OWNER TYPE E 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑ 3. PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7. FEDERAL 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Shell Oil Products US 310-816-2027 <br /> MAILING OR STREET ADDRESS 416 <br /> 20945 S. Wilmington Ave. <br /> CITY 417 1 STATE 416 ZIP CODE 419 <br /> Carson CA 90810 <br /> TANK OWNER TYPE E 1.CORPORATION [:12.INDIVIDUAL [:14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3. PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 0 1 3 1 9 I 0 2 6 i Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE E 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE ❑5.LETTER OF CREDIT (18.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑ 3. INSURANCE ❑ 6. EXEMPTION [19.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. IE 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 APPLICC DATE ata PHONE azs <br /> 3/30/2004 (707) 765-1660 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Steve Skanderson Agent for Shell Oil <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> San Joaquin County.OES RORO <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />