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FIED PROGRAM CONSOLIDATED FO ;' ., i' <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILIMR - 5 M <br /> (on qjpa.9e per s i,1, <br /> 11 Eape of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION SITE ,/ 0111Y <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE I 400 <br /> i '�, 1 3 X33 1 .. 311i9� f■13..KH� 3` 33N3,r` A+'['�:"��'. s _b.#.,3a 3 # 3 "11 3 11�33 33)x3',"r9 tf€ <br /> tE dg +R € � ,,,,, Ci1��T"Yiil15 :. ✓ 1 � 5Y 9 3 I 31 13.,x11 t3 <br /> ....� <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 1: tulll <br /> Grant Line Shell <br /> €z 3 �fi 1 <br /> 2375 W. Grant Line Road,Tracy CA 95386 �, �,�"„ <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> 1-205 9 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM E15. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP [:17.FEDERAL AGENCY* 402 <br /> 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 <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 4 404 ❑ Yes ® No 405 406 <br /> 3 �x ar <br /> �Gf�f r£S''�c'���k '� it <br /> :�! <br /> PROPERTY OWNER NAME 407 1 PHONE 408 <br /> Shell Oil Products US 310-816-2027 <br /> MAILING OR STREET ADDRESS 409 <br /> 20945 S.Wilmington Ave. <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Carson CA 90810 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL 413 <br /> ��$ <br /> .s, m ?�: 4 -' .. i,. 11.,.:1••� tit. <br /> R <br /> TANK OWNER NAME 414 PHONE 415 <br /> Shell Oil Products US 310-816-2027 <br /> MAILING OR STREET ADDRESS 416 <br /> 20945 S.Wilmington Ave. <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Carson CA 90810 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2. INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [:17. FEDERAL AGENCY <br /> ',- <br /> uF <br /> TY TK HQ 44- 1 0 3 9 0 2 6 1 Call 916 322-9669 if questions arise 421 <br /> rWHEN <br /> r�t <br /> >r <br /> x h,,�" �� <br /> '..�3, £ . .... ..Y.`� �.� ..€.En• r. € ui.0.:..., s: `*,,,£:� X13., ..��. �� ..t. <br /> INDICATE ® 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VIM,- <br /> � 011 <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 ®2. PROPERTY OWNER [13.TANK OWNER 423 <br /> tlri ., <br /> rFSa��`� � K, .w , ' <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE azoPHONE azs <br /> 3/30/2004 (707)765-1660 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Steve Skanderson Agent for Shell Oil <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> San Joaquin County,OES CORO RO <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />