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0 IFI ROGRAM CONSOLIDATED F <br />Im <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(One page per site) Page 1 of 7 <br />TYPE OF ACTION ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENTLY CLOSED SITE 400. <br />(Check one item only) ❑ 4. AMENDED PERMIT (Specify change) ® 8. TANK REMOVED <br />❑ 6. TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3. <br />FACILITY <br />ID# <br />1 <br />1• <br />NEAREST CROSS STREET 401. <br />FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT* 402• <br />Country Club Shell, 2575 Country Club Blvd., Stockton <br />® 1. CORPORATION ❑ 5. COUNTY AGENCY* <br />7 ❑ 2. INDIVIDUAL [16. STATE AGENCY* <br />BUSINESS ® 1. GAS STATION [13. FARM ❑ 5. COMMERCIAL 40_3 <br />TYPE [12. DISTRIBUTOR [14. PROCESSOR ❑ 6. OTHER <br />[13. PARTNERSHIP ❑ 7. FEDERAL AGENCY* <br />TOTAL NUMBER OF TANKS 404. <br />Is facility on Indian Reservation 405. <br />* If owner of UST is a public agency: name of supervisor of division, section or 406• <br />REMAINING AT SITE <br />or trust lands? <br />office which operates the UST. (This is the contact person for the tank records.) <br />0 <br />❑ Yes ® No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />PHONE 408. <br />Shell Oil Products, c/o Bill Merchant <br />916.684.6125 <br />MAILING OR STREET ADDRESS 409 <br />9141 E. Stockton Blvd., Suite 250-321 <br />CITY 410• <br />STATE 411• <br />ZIP CODE 412. <br />Elk' Grove 1 <br />CA <br />95624 <br />PROPERTY OWNER TYPE 0 1. CORPORATION 2. INDIVIDUAL 0 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY 413. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />PHONE 415. <br />Shell Oil Products, c/o Bill Merchant <br />916.684.6125 <br />MAILING OR STREET ADDRESS 416. <br />9141 E. Stockton Blvd., Suite 250-321 <br />CITY 417. <br />STATE 418. <br />ZIP CODE 419. <br />Elk Grove 1 <br />CA <br />95624 <br />TANK OWNER TYPE ® 1. CORPORATION ❑ 2. INDIVIDUAL L1 4. LOCAL AGENCYIDISTRICT ❑ 6. STATE AGENCY 420. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />W. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- 1 0 3 1 9 1 0 1 2 1 6 Call 916 322-9669 if questions arise 421. <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) ® 1. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />422 <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT [18. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <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 I or 2 is checked. ❑ 1. FACILITY [12. PROPERTY OWNER ❑ 3. TANK OWNER 423• <br />VII. APPLICANT SIGNATURE <br />Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATUR PPLICANT <br />DATE 424• <br />PHONE 425• <br />w r-� SA&V- <br />916.631.1300 ext. 19 <br />NAME OF APPLICANT (print) 426• <br />_66/0/0c/ <br />TITLE OF APPLICANT 427. <br />Torn Piskor (Agent for Shell Oil Products) <br />Project Manager <br />STATE UST FACILITY NUMBER (Agency use only) 428• <br />1998 UPGRADE CERTIFICATE NUMBER (Agency use only) 429. <br />(See Data Element 1, above. <br />UPCF Hwfwrc-a (1/99) -1/2 http://www.unidocs.org Rev. 02/16/00 <br />