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ED PROGRAM CONSOLIDATED FO% <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) a e 1 <br /> of 9 <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change)New overfill and dispenser containment [18.TANK REMOVED / <br /> ❑6.TEMPORARY SITE CLOSURE I/ <br /> 5 <br /> I. FACILITY/SITE INFORMATION 3 7 T <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> Grant Line Shell 2375 Grant Line Rd. Tracy,CA ID# 1. <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> I-205 ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS® 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403• ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404• Is facility on Indian Reservation 405• *If owner of UST is a public agency: name of supervisor of division,section or 406• <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 4 ❑Yes ONO N/A <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> E uilon Enterprises,LLC C/O Bruce T. Marubashi,Permit Analyst 925 766-3498 <br /> MAILING OR STREET ADDRESS 409. <br /> P.O.Box 8509 <br /> CITY 410. FSTATE 411. ZIP CODE 412. <br /> San Jose I CA 95155 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION [12.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> E uilon Enterprises,LLC C/O Bruce T. Marubashi,Permit Analyst (925)766-3498 <br /> MAILING OR STREET ADDRESS 416. <br /> P.O.Box 8509 <br /> CITY 417. FSTATE 418. ZIP CODE 419. <br /> San Jose I CA 95155 <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 /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HO 44- 1 0 3 1 9 1 0 1 2 F-6-T Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑99.OTHER: <br /> [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <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 /> VII.APPLICANT SIGNATURE <br /> Certification: 1 certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGN URE Of,LIC�ANT DATE 424. 425. <br /> �y PHONE <br /> 6 Z (707)789-3255 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Tom Piskor(Agent for Equilon Enterprises,LLC) Design Development Manager <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />