COMPLIANCE INFO_1995-2004 - Laserfiche WebLink

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11110111WIFIED PROGRAM CONSOLIDATED FORMaot PR#:PR0231070 FAC#:FA0006439 UNDERGROUND STORAGE TANKS -FACILITY (one page per site) TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4_AMENDED PERMIT ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 2575 COUNTRY CLUB BLVD,STOCKTON BUSINESS NAME(wire as FAuLITY NAME or DBA-Doing Business As) 3 FACILITY IDMPR ID# COUNTRY CLUB SHELL* FA0006439 PR0231070 1 NEAREST CROSS STREET FACILITY OWNER TYPE COUNTRY CLUB 401 F-1I.CORPORATION ❑ 4.LOCAL AGENCY/DISTRICT* ❑ S.COUNTY AGENCY* BUSINESS ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL 6.STATE AGENCY* ❑ TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY* 402 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 which operates REMAINING AT SITE ttustlands? the UST(This is the contact person for the tank records.) 404 [1 Yes No 405CRAIG FURGISON 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407PHONE S 408 209 957-5398 MA LING OR STREET ADDRESS fo1J�S t 1�31 a i 409 PO BOX 4848 Gc-v + v CITY 410 STATE 411 ZIP CODE 412 ANAHEIM CA 92803 PROPERTY OWNER TYPE ® I.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 SHELL OIL COMPANY 209 957-5398 MAILING OR STREET ADDRESS 416 PO BOX 4023 CITY 417 STATE 418 ZIP CODE 419 CONCORD CA 194524 TANK OWNER TYPE 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-024520 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER O 99.OTHER ❑3.INSURANCE ❑ 6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® 1.FACILITY ' ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 1 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY NUMBER(For local re only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)