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FIED PROGRAM CONSOLIDATED F019, <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> APR - 5 Zuu�ANKS <br /> (one page pmt, �►' f1a)• <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ L SITE <br /> (Check one item only) [14.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> ,uP / } 1, rU` ', (+ 3 } £sem i <br /> 3 �3, Ips 03 I t ©N <br /> F4 &T, <br /> „ <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 1 Ilf+�r� <br /> Shell Food Mart <br /> 2320 North EI Dorado Street,Stockton CA 95204 t7 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> Hampton ® 1.CORPORATION El5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION El3.FARM [15. 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 /> r R` ' <br /> IER+ry 1,Y�O��� <br /> 3 <br /> PROPERTY OWNER NAME 407 PHONE 406 <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 ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL 413 <br /> q <br /> v <br /> 03 ,wu � <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 STATE 418 ZIP CODE 419 <br /> Carson CA 90810 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL 0 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> r si <br /> IEr3 4F Eta " N UST S FEE 111ti11 �= 'h� <br /> TY TK HQ 44- 1 0 3 9 0 2 6 Call 916 322-9669 if questions arise 421 <br /> F <br /> LW'91 <br /> . Y <br /> ) � <br /> .....v;vww <br /> INDICATE ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE 0 5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> EW <br /> BNis { <1T1F ? AN 1. al '' 01 A <br /> �. 6 ",r 7 �, 3 3 P'3 f$ 3 r+ R.. t' <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. ® 1.FACILITY [12. PROPERTY OWNER ❑3.TANK OWNER 423 <br /> 3 v. 3 .ya, ..fi3g "01 <br /> 3'It <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT 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(Forlocal useonly) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal use only) 429 <br /> San Joaquin County,OES RORO <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />