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P3 93 <br /> IED PROGRAM CONSOLIDATED FOle V- <br /> TANKS 13 <br /> UNDERGROUND STORAGE TANKS - FACILITY ����!�p 217/0` <br /> (One page per site) Page t of 7 <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) ®8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> L FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DRA-Doing Business As) 3. FACILITY <br /> ID#F4 6 _ <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT" 402. <br /> Country Club Shell, 257$Coun Club Blvd., Stockton ® 1.CORPORATION El 5.COUNTY AGENCY' <br /> BUSINESS ® I.GAS STATION 3.FARMLj S.COMMERCIAL 403. [12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR ❑6.OTHER [13.PARTNERSHIP [17.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 /> 0 ❑Yes ®No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Shell Oil Products,c/o Bill Merchant 916.684.6125 <br /> MAILING OR STREET ADDRESS 409. <br /> 9141 E. Stockton Blvd., Suite 250-321 <br /> CITY 410. STATE 411. ZIP CODE 412, <br /> Elk Grove CA 95624 <br /> PROPERTY OWNER TYPE ® I.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IIL TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> Shell Oil Products,c/o Bill Merchant 916.684.6125 <br /> MAILING OR STREET ADDRESS 416. <br /> 9141 E. Stockton Blvd., Suite 250-321 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Elk Grove CA 95624 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT Lj 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 0 1 3 1 9 1 0 1 2 1 6 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®I.SELF-INSURED [14.SURETY BOND [17.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> [12.GUARANTEE [15.LETTER OF CREDIT [18.STATE FUND&CFO LETTER [199 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 l or 2 is checked. ❑ I.PACILIIY ❑2. PROPLRIYOWNLR E] 3. 1ANK OWN LR423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATUR PPLICANT DATE 424. PHONE 425. <br /> � 6�r F.,X_ SPIAL- 007/0y 916.631.1300 ext. 19 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Tom Piskor(Agent for Shell Oil Products) Project Manager <br /> STATE UST FACILITY NUMBER(Agency uc only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency ase only) 422 <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />