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UNIFIED PROGRAM CONSOLIDATED FORM
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION
<br /> (One form per facility)
<br /> TYPE OF ACTION ❑ I.NEW PERMIT ® 5.CI-IANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4GO'
<br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT
<br /> } ..Ptt41,t^t'•,.P.4.r.)..44
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<br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID Il
<br /> 4 (Agency Use Only)
<br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3.
<br /> Grant Line Shell #136187
<br /> BUSINESS SITE ADDRESS 103• CITY 104'
<br /> 2375 W.Grant Line Road Trac
<br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403• Is the facility located on Indian Reservation or 405.
<br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No
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<br /> PROPERTY OWNER NAME 407. PHONE 408
<br /> Equilon Enterprises LLC I Shell Oil Products US (310) 816-2207
<br /> MAILING ADDRESS 409'
<br /> 12700 Northborough Dr. Oto. STATE 411• ZIP CODE 412'
<br /> CITY
<br /> Houston TX 77067
<br /> I t v, N SS'• aye JS H'h!J h- t.PR $b
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<br /> F •n.r:'a..(
<br /> TANK OPERATOR NAME 429-1 PHONE 428-2
<br /> John R. Edwards, Inc. 209-836-8908
<br /> MAILING ADDRESS 429-3
<br /> 3649 Jamison Way
<br /> CITY 4294 STATE 429-5 ZIP CODE 428-6
<br /> Castro Valley CA 94546
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<br /> TANK OWNER NAME 414. PHONE a1s
<br /> E uilon EnteRESSr rises LLC/Shell Oil Products US (3 10)
<br /> 816-2207
<br /> MAILING ADD410'
<br /> 12700 Northborough Dr.
<br /> CITY 417. STATE 419. 1 ZIP CODE 419•
<br /> Houston TX 77067
<br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420'
<br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT
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<br /> TY(TK)HQ 44- 0 3 9 0 2 6 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421'
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<br /> 'us T H LD�R .O TI 1®' ��,, .� 1} { )5y�•
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<br /> Issue permit and send legal notifications and mailings to: C31.FACILITY OWNER [14.TANK OPERATOR an
<br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR
<br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406
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<br /> CE I ION: I ertif that information provided herein is true,accurate,and in full compliance with le al requirements.
<br /> A LICA I N T QQ DATE 424• 1 PHONE 425.
<br /> 11/11/2009 916-240-1610
<br /> AAP ICA NAME(print 426• APPLICANT TITLE 427
<br /> Aura Sibl y for Shell i Prod cts US HS&E Compliance Coordinator
<br /> UPCF UST-A Rev.(12/2007)
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