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3 b3 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page I or <br /> TYPE OF ACTION r 1.NEW SITE PERMIT X 3.RENEWAL PERMIT 15.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one iteral only) r 2.NEW OPERATOR r 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> r 6 TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-doing Business As) 3 FACILITY ID If 1 <br /> Ripon Shell, Dave Posey <br /> 341 E.Main Street, Ripon, CA95366 FA M -3 7S-3 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCYlDISTRICT- <br /> HWY 99 EPA#CAR000114876 X 1. CORPORATION r 5. COUNTYAGENCY- <br /> BUSINESSTYPEr 2. INDIVIDUAL_ r 6. STATEAGENCY' <br /> X 1.GAS STATION r 3.FARM r 5.COMMERCIAL r 3. PARTNERSHIP <br /> r 2.DISTRIBUTOR r 4.PROCESSOR r 6.OTHER r 7. FEDERAL AGENCY' 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or -11 owner of UST is a public agency:owne u(supervisor of <br /> REMAINING AT SITE trustlands. division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 404 2-15M `96 r Yes X No 405 406 <br /> 11,PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Shell Oil Products US CIO Bruce T.Marubashi, Permit Analyst 1925-766-3498 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O.BOX 8509 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> SAN JOSE CA 95155 <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> X1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> SAME AS If <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY!DISTRICT r 6. STATL AGLNCY 420 <br /> F 1. CORPORATION r 3. PARTNERSHIP r 5 COUNTYAGENCY r 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 1_-]]O 3191012161 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) X 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE r 5. LETTER OF CREDIT r 8. STATE FUND&CFO LETTER r 99 OTHER <br /> r 3. INSURANCE r6 EXEMPTION r 9. STATE FUND A CD 422 <br /> Check one box to indicate which address should be used for legal notirications and mailing. X 1. FACILITY r 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Legal notirzations and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification: I certify that Vle information provided Therein is true and accurate to the best of my knowledge. <br /> SIGMA \ <br /> EOFAPPLICAN� DATE 424 PHONE <br /> 4/29102 925-766-3498 425 <br /> APPLICANT(prinry TITLE OF APPLICANT 427 <br /> BRUCE T.MARUBASHI for Shell Oil Products 426 HSE Analyst <br /> STATE UST FACILITY NUMBLK(For local use only) 426 1998 UPGRADE CERTIFICATE NUMBER(Forkecel use only) 429 <br /> UPCF(1199 revised) 5 Formerly SVi Form A <br /> 2 'd 11P913S-GLS-1302 TgsegnjeW •1 eonig dS2 :E0 20 62 idd <br />