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FIED PROGRAM CONSOLIDATED FOFqp <br /> UNDERGROUND STORAGE TANKS - FACILITY A?R - Z JTkPKS <br /> (one page per sRW,i!_,( Page, _Pt;JV , <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ 7.P R L L''t <br /> td8r&WM YL"' <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> /, 333 3 �, I.`3h►(GIL ITY!SI" II+IURI4ATI� Milk <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3FA rIIL :2� 3 <br /> Waterloo Shell Foodmart 1 <br /> 4315 Waterloo Road,Stockton CA 95205 '� 3 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> Piccoli Road ® 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❑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 /> 2 404 ❑ Yes ® No 405 406 <br /> 3 <br /> IM <br /> PRPERTY C) N ATT , <br /> Q " <br /> �, <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 ® 1.CORPORATION [:12.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL 413 <br /> 14 <br /> ", 333 3 � TJ���, Rey �gJ'h <br /> AN WNL I <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 an STATE 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 /> IY ,13 �1ALIZATIO 'UST `rTS ;G FE ?UNT BER y � <br /> � � �"`�� ��.� -/ � �t;��t�.�CG,.,....<<... , 3 .. ,.. I* .,.�„''..'S r�:,.,,Y -,m �>�,. ,�.�;, p3J!x✓� E, �, .s`i,: <br /> TY TK HQ 44- 1 0 3 9 0 2 6 Call 916 322-9669 if questions3 arise 421 <br /> 3.... <br /> % 3 a <br /> 3 PETR© U FINAN I3ILJTY <br /> A3 .. <br /> INDICATE ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> '4`` <br /> w <br /> 1 x 1/I LEGAL IT ICATI©N ANDS AIS 13 <br /> 3 <br /> ..,.. .,�-`T ?... , ..,_j 3 " ..? <br /> 3 <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 ❑2. PROPERTY OWNER [13.TANK OWNER 423 <br /> TURF � .., F x <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICAN 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 />