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FIED PROGRAM CONSOLIDATED FO[jjq�, <br /> N11a/oe" TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY APR - 5 M <br /> (one page per sit y.jft ptaj- ,jp!!� <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ 7.PER VL 6f ` <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> RM <br /> 1:= FACiLITX I E', <br /> IIS 3 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) g ;;FArsI.I <br /> Fremont Shell 1 <br /> 2494 E. Fremont Street, Stockton CA 95205 4,,, <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> Filbert ® 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS ® 1.GAS STATION [13.FARM ❑5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR [14.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 /> 3 404 ❑ Yes ® No 405 406 <br /> AA <br /> Comm <br /> NFORMATI ?N y <br /> i' � <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 ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ,r ❑3.PARTNERSHIP El5.COUNTY AGENCY ❑ 7.FEDERAL 413 <br /> IIIEI INFfRI4 / �13 gaL <br /> 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 STATE 418 ZIP CODE 419 <br /> Carson CA 90810 <br /> TANK OWNER TYPE ® 1.CORPORATION [:12.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> / 3 hl 3'iv '/� <br /> BtAl7► ��+ IU,�;� ATICN UST` fitlt:,FEECI77 ��NUI6_ <br /> .,.�.», 3d. <br /> ..... ..,, <br /> TY TK HQ 44- 0 3 9 0 2 6 Call 916 322-9669 if uestions arise 421 <br /> 1 ; �� t 3 v <br /> �4 ! v1 C &SIM UST FIN 1 SPIDN � 1 <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 /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> l 3v, r <br /> 1/ISAI-NOTIFICATIQ <br /> A' l .,r _L <br /> ,... ,3 ,. ...:... ., c <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 /> WWI <br /> V311PPLi SWAT. .. <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(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 />