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( 1 UED PROGRAM CON LIATED *M <br /> i aI'I �63 <br /> 1 � TANKS <br /> UNDERGROUND STORA ADNKS - FACIu 12N <br /> CJ (( 03 (one page per site) <br /> TYPE OF ACTION r 1.NEW SITE PERMIT X 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- r 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) r 2.NEW OPERATOR4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> I� <br /> F 6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 <br /> Ripon Shell, Dave Posey <br /> 341 E. Main Street, Ripon, CA95366 FA 3-1;5'3 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCY/DISTRICT' <br /> HWY 99 EPA# CAR000114876 X 1. CORPORATION h 5. COUNTY AGENCY- <br /> BUSINESS TYPEr 2. INDIVIDUAL r 6. STATE AGENCY' <br /> X 1.GAS STATION r 3.FARM r 5.COMMERCIAL r 3. PARTNERSHIP <br /> F 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 'If owner of UST is a public agency:name of 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 F Yes X No 405 406 <br /> ll.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Shell Oil Products US C/O Bruce T. Marubashi, HSE Permit 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 h 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> X 1. CORPORATION IF 3. PARTNERSHIP r 5. COUNTY AGENCY I' 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> SAME AS II <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> TANK OWNER TYPE I' 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> 11. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 4 1 - 1013191012161 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHOD(S) X 1. SELF-INSURED h 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> F 2. GUARANTEE h 5. LETTER OF CREDIT r 8. STATE FUND&CFO LETTER r 99. OTHER: <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. X 1. FACILITY h 2. PROPERTY OWNER h 3. TANK OWNER 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <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 1 PHONE <br /> 8/29/03 925-766-3498 425 <br /> NAME OF APPLICANT(print) TITLE OF APPLICANT 427 <br /> BRUCE T. MARUBASHI for Shell Oil Products 426 HSE Permit Analyst <br /> STATE UST FACILITY NUMBER(For local use only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 5 Formerly SWRC13 Form A <br />