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y/a Uy " <br /> FIED PROGRAM CONSOLIDATED FOFV <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> APR - 5 ���TANKS <br /> (one a <br /> p 3. <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑63EMPORARY SITE CLOSURE 400 <br /> �,. AII � <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> Country Club Shell '- <br /> 2575 Country Club,Stockton CA 95204 # � <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> Plymouth ® 1.CORPORATION ❑ 5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION [13.FARM ❑5. COMMERCIAL ❑ 2. INDIVIDUAL ❑ 6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. 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 /> 3 404 ❑ Yes ® No 405 406 <br /> " © 1N.FORMATI©l /// �y : 'Ej <br /> i,i ,�+ . u <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 TSTATE 411 ZIP CODE 412 <br /> Carson CA 90810 <br /> PROPERTY OWNER TYPE 0 1.CORPORATION ❑2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL 413 <br /> v y// 43 %3 <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 TSTATE 418 ZIP CODE 419 <br /> Carson CA 90810 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> �+ = 3 33 tly01 <br /> // 3 ,\SG <br /> MM <br /> IIN.BOM OF ECaU IZATIOI+f J�T S' ORAGE FEE A,M, y �tiEER <br /> '. ,,.<< - .. iii} ?;,,„, ,%� ,,;I'�, •,i, s„ 3v�a-,F�`.. ...i. <br /> TY TK HQ 44- 1 0 1 3 9 0 1 2 1 6 1 Call 916 322-9669 if questions arise 421 <br /> St <br /> �S �\�A <k <br /> f, <br /> INDICATE ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE [:15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> 3/a 33333'i/ "� <br /> l333 ' 3 i�/ Eta C"CFCATI ?Nl EE / <br /> ,.�3as��Enp, <br /> 0410�. p <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 bo�Ax��1 or 2 is checked. ® 1.FACILITY [12. PROPERTY OWNER [13.TANK OWNER 423 <br /> A0PN '- / e 3 '\�'o - �\ r i ITJR 3 ,fuv�y` <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLIC#W DATE 424 PHONE 425 <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 />