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LIED PROGRAM CONSOLIDATED FOIE <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page_1_of 9 <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400• <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change)EVR 102B&UDC Upgrade ❑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, FACILITY <br /> 1 <br /> Shell Mini Mart3725 Tracy Blvd Tracy ID# <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402• <br /> W.Larch Road ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403. [12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR [16.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency:name of supervisor of division,section or 406. <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 4 ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Shell Oil Products C/O Bruce Marubashi,H,S&E Analyst 925-766-3498 <br /> MAILING OR STREET ADDRESS 409. <br /> 3468 Claremont Avenue <br /> CITY 410. STATE 411• ZIP CODE 412. <br /> Modesto CA 95350 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL [:14.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. PHONE 415. <br /> Shell Oil Products,LLC C/O Bruce Marubashi,H,S&E Analyst 925-766-3498 <br /> MAILING OR STREET ADDRESS 416. <br /> 3468 Claremont Avenue <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Modesto CA 95350 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY JK HQ 44- 1 0 3 1 9 1 0 1 2 1 6 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED [14.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM 422. <br /> ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.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 ®2. 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 /> SIGNATURE OF L ANT DATE 424. PHONE a2s. <br /> r/�/ - r-.rc- 51•f 916-631-1300 ext. 19 <br /> NAME OF APPLICANT(print) 426. TITLE OFAPPLICANT 427. <br /> Tom Piskor(Agent for Shell Oil Products) Project Manager <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 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 />