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Y112- 6 d� - <br /> FIED PROGRAM CONSOLIDATED FOFW <br /> UNDERGROUND STORAGE TANKS - FACILITY REOEM <br /> (one page per site) g& <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT 0 5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) [14.AMENDED PERMIT specify change local use only ❑ 8.TANptttV01N WU4�t <br /> ❑&TEMPORARY SITE CLOSURE �vd t�d�;fRGfhV�V 66RIJ GE00 <br /> AQ <br /> TO <br /> Q I§ r <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 '11 <br /> Shell & Mini Mart 1 <br /> 3725 Tracy Boulevard,Tracy CA 95376 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> 1-205 on-ramp ® 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 [17.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 /> 4 404 ❑ Yes ® No 405 406 <br /> llyar, �l33 r, :. <br /> r <br /> iX•sraT,_,h ...U...,e <br /> MITI <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 /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL 413 <br /> 3 r� af3 47d .+ kyr a � - - • <br /> ry <br /> 33 rz xa <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 El 2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> r r € t� .� x <br /> k ' II+� It j • 3€ i' ] }9 3i �9 <br /> �'.t ,`'`'' 3�' - I � � ,� �a 4i. Arses •,Sa i. 9 .,, ,€: <br /> TY TK HQ 44- 1 0 1 3 19 1 0 12 1 6 1 Call 916 322-9669 if questions arise 421 <br /> �. ( '!�f ..: a 333 <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 (.�y1'i 3 Ir j4:a33 h'` 1 l : Y '�' ". k Y3. 3r F <br /> �'a ` ria Yl 1wT �ff A7 <br /> 0o ,.3i, <br /> . k ) <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 02. PROPERTY OWNER [13.TANK OWNER 423 <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 useonly) 429 <br /> San,Joaquin County,OES CORO RO <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />