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UN OED PROGRAM CONSOLIDATED F41M U1n <br /> 'L TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (?7�/ O (one page per site) <br /> TYPE OF ACTION r 1.NEW SITE PERMIT F 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify change- I 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) <br /> I 2.NEW OPERATOR F 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <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 /> Shell Food Mart, R&K Lutz w <br /> 2320 N EI Dorado St., Stockton, CA 95204 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE F 4. LOCAL AGENCY/DISTRICT- <br /> Hampton <br /> GENCY/DISTRICT' <br /> Ham ton Street X 1. CORPORATION <br /> p 2. INDIVt 5. COUNTY AGENCY' <br /> T' IDUAL <br /> BUSINESS TYPE X 1.GAS STATION F 3.FARM r 5.COMMERCIAL r 3. PARTNERSHIP r 6. STATE AGENCY' <br /> F 2.DISTRIBUTOR F 4.PROCESSOR F 6.OTHER I 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 3 F Yes X No 405 406 <br /> II.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Shell Oil Products US C/O Bruce T. Marubashi, HSE Analyst 925-766-3498 <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 F 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 413 <br /> X 1. CORPORATION F 3. PARTNERSHIP F 5. COUNTY AGENCY IF 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 F 2. INDIVIDUAL F 4. LOCAL AGENCY/DISTRICT F 6. STATE AGENCY 420 <br /> I 1. CORPORATION F 3. PARTNERSHIP F 5. COUNTY AGENCY F 7. FEDERAL AGENCY <br /> If Ot')ARPOEF:Q"AI17ATIONi'SISInRAGFEI=F:ACCnIININIIMRFR <br /> TY(TK)HO 4 4 0 3 9 0 2 E Call(916)322-9669 if gUestions arise 421 <br /> TY(TK)HQ__F_74 <br /> V RUROI Ell IM I ISI FEINANCIAI RESPONSIRII 1324 <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 F 5. LETTER OF CREDIT F 8. STATE FUND&CFO LETTER r 99. OTHER: <br /> F 3. INSURANCE F 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 I 2. PROPERTY OWNER r 3. TANK OWNER 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> VII A12121 ICANT SIGNAIIIRE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNAT E OF APPLIC 02 <br /> DATE 424 PHONE <br /> 6/7/02 925-766-3498 425 <br /> NAME OF APPLICANT(print) TITLE OF APPLICANT 427 <br /> BRUCE T. MARUBASHI for Shell Oil Products 426 HSE Analyst <br /> STATE UST FACILITY NUMBER(For local use only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> I <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />