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U ED PROGRAM CONSOLIDATED FOR
<br /> UNDERGROUND STORAGE TANK
<br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION
<br /> (One form per facility)
<br /> TYPE OF ACTION ❑ L NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400.
<br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT
<br /> y 2
<br /> 404.
<br /> TOTAL NUMBER OF LISTS AT FACILITY
<br /> FACILITY ID#
<br /> 4 (Agency Use Only)
<br /> BUSINESS NAME(Same as FACILITY NAIME or DBA-Doing Business As)
<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
<br /> .�.} 1( t-1,sl sys 'f r\ \1 ,>< �- � 4- ,< a , � -cr _.. y,, :•..,a.u: �-},.' y-,.,4:. u�f/,IF,r A- r ti:�.4 ri`s�1 .-;�lr i(6/_;1•M1f�t,t,,
<br /> `PROPERTY OWNER INFORMATIONY rr t. < } r f t ,
<br /> ,:: ,.,..•."'I� �f,ix`n4-v!!' (.x t..,�x.f,.., .1 .\t...,r „- 1.,. �.eti r.....a. ..2 t i,.m:!ti�.c...,.v...x i,. 4 ,a.�;..rr :v:^�.r Y :iv.U;,.•Mt tF..,Lntn:.L.rr.r<q T.,/ r•..1 •/,..C:2 ,a r J.:h'.�_.S ,,.�?rh,,lT!>Yc+k x(�'.r4}'.-
<br /> PROPERTY OWNER NAME 407" PHONE 409.
<br /> Equilon Enterprises LLC/Shell Oil Products US (310) 816-2207
<br /> MAILING ADDRESS 409.
<br /> 12700 Northborough Dr.
<br /> CITY 410. STATE 411" ZIP CODE 412.
<br /> Houston TX 77067
<br /> OPERATOR INFORMATION
<br /> TANK OPERATOR NAME 429-1. PHONE 429.2
<br /> John R. Edwards, Inc. 209-836-8908
<br /> MAILING ADDRESS 428-3
<br /> 3649 Jamison Way
<br /> CITY 4294 STATE 429-5 ZIP CODE 428-6
<br /> Castro Valley CA 94546
<br /> Wow r7:t! P .i..• 3•�. .,:rc,f.t t A+';yr s:r a ,} r �yEra r�i 'INtt !��,.�r w 1, ix:. (, r.rrt°dY ttrt -.
<br /> r ��
<br /> AN1\.
<br /> N T YNFORMATION
<br /> 1 t �7 n..R..
<br /> TANK OWNER NAME 414. PHONE 415.
<br /> E uilon Enterprises LLC /Shell Oil Products US (310) 816-2207
<br /> MAILING ADDRESS 416"
<br /> 12700 Northborough Dr.
<br /> CITY 417. STATE 418. 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 ® 8.NON-GOVERNMENT
<br /> V.M1BOARDfOF EQUALIZATIONYUST ST®RAGE FEE ACCOUNT
<br /> TY(TK)HQ 44- 0 1 3 19 1 0 2 1 6 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421.
<br /> PERMITIIdOLDER INFORMATION r --. r G
<br /> +/.,,. .. i . . i
<br /> .:+.va,rae„wxs;fA�h.d (,,,.-.Yr/��edr,;..1.eebx_.a..;,n �x.•k v,rt.1+?°Jrd.YY. #^. e. ,n ..
<br /> 423
<br /> Issue permit and send legal notifications and mailings to: [IL FACILITY OWNER ❑ 4.TANK OPERATOR
<br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR
<br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406.
<br /> CE I ON: I ertif that information provided herein is true,accurate,and in full compliance with legal requirements.
<br /> A LICV
<br /> T DATE 424. PHONE 425.
<br /> 11/11/2009 916-240-1610
<br /> APP IC (print) 426. APPLICANT TITLE 427
<br /> Aura Shell it Prod cts US HS&E Com liance Coordinator
<br /> UPCF UST-A Rev.(12/2007)
<br />
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