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FIED PROGRAM CONSOLIDATED F <br /> UNDERGROUND STORAGE TANK ILITY APR - 5 200� <br /> c(/� (one page per site Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ TPERAIM WCC .: 't r <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> � �k k <br /> ��, .s <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> Ripon Shell 1 <br /> 341 E. Main Street, Ripon CA 95366 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> Highway 99 E 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. 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 /> 2 404 ❑ Yes ® No 405 406 <br /> ) N FR14 ' z�� z <br /> '1 X33 1 p ITY Ow ERINT <br /> (i/,y z, 3y,F.^, ,. F...2 . .':�., ,.3T, c:3 ,gx,x... 3irT <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 [14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7.FEDERAL 413 <br /> FQIMATi <br /> tf £ <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 ala ZIP CODE 419 <br /> Carson CA 90810 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY <br /> Ill SOARI} t� T STQ ) ! M@ER <br /> ,.. W37P <br /> TY TK HQ 44- 1 0 3 9 0 2 1 6 1 Call 916 322-9669 if questions arise 421 <br /> 'ETRt"? .EUM ' y S r sIMI, <br /> INDICATE ® 1.SELF-INSURED [:14.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 [19.STATE FUND&CD 422 <br /> N � AL l� TIIICAy51 <br /> AQDRESS 3} qq <br /> .r£ <br /> M <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 [12. PROPERTY OWNER ❑3.TANK OWNER 423 <br /> APPLICANT SSV .. q � <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLIfANT 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 />