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IFIED PROGRAM CONSOLIDATED FORn PR#:PRO231084 4k # NO FAC#:FA0006447 UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT jillIfffilliIIISM❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 2320 N EL DORADO ST,STOCKTON BUSINESS NAME(Same as FACILRY NAME or DBA-Doing Business As) 3 FACILITY IDI I PR ID# SHELL FOOD MART* FA0006447 PR0231084 1 NEAREST CROSS STREET FACILITY OWNER TYPE DORADO 401 ❑ 4.LOCAL AGENCY/DISTRICT- EL ® 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE ❑2 DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ * 402 7.FEDERAL AGENCY 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 which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) aoa ❑ yes ® No 405KENDRICK,JOHN&ROBERT L 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE( C3r j 408 /J/ 7 MAILING OR STREET ADDRESS 409 anonc eULU U CT NV- CITY410 STATE 411 ZIP CODE 412 1't- <.,._.)-t?"(_"i fir- 8-' d Q PROPERTY OWNER 1.CORPORATION 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHOU484�11_3' 415 L� f/C--' /- & <- MAILING OR STREET ADDRESS 416 E a �r�pCfU CITY 417 STATE 418 ZIP CODE 419 TANK OWNER TYPE 1.CORPORATION .INDIVIDUAL El4.LOCAL AGENCY/DISTRICT El6.STATE AGENCY 420 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- -4 - Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 1:12.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTERX❑99.OTHER 113.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® I.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNAT FAP LI NT DATE 424 PHONE 425 NATAf zPL CANT( nt 7�1 426 TITLE OFAPPLICANT 427 l/ Civ ► STA UST FACILITY NIJMFIER(For local uc only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)