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I `FIED PROGRAM CONSOLIDATED FOY <br /> ,%W TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page l of 7 <br /> TYPE OF ACTION ❑ L NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 406 <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ®8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3, FACILITY <br /> 1D# 1 <br /> Ben-Holt/I-5 Shell 3011 W Benjamin Holt Dr Stockton <br /> NEAREST CROSS STREET 4oi. FACILITY OWNER TYPE 4.LOCAL AGENCY/DISTRICT* 402, <br /> Grisby Place ® 1.CORPORATION ❑S.COUNTY AGENCY* <br /> BUSINESS D9 1.GAS STATION 3.FARM [15.COMMERCIAL 403. ❑2,INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [:14.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 44• 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 /> 2 ❑Yes ONO <br /> II. 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, Ste 250-321 <br /> CITY 410. STATE 411 ZIP CODE 412 <br /> Elk Grove CA 95624 <br /> PROPERTY OWNER TYPE 0 1.CORPORATION 0 2.INDIVIDUAL I 14-TOCAI AGENCY/DISTRICT 0 6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> Shell Oil Products,LLC c/o Bill Merchant 916-684-6125 <br /> MAILING OR STREET ADDRESS 416. <br /> 9141 E. Stockton Blvd,Ste 250-321 <br /> CITY 417. STATE 418. ZIP CODE 419, <br /> Elk Grove CA 95624 <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TIG HQ 44- 1 0 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) ®1.SELF-INSURED ❑4,SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 42 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER 0 99.OTHER: <br /> ❑3.INSURANCE [16.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 I or 2 is checked. ❑ I.FACILITY ❑2. PROPERTY OWNER [13.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATUREICANT DATE 424. PHONE 425. <br /> (,.- ! /o2t, d 7 d 7 (j 916-631-1300 ext. 19 <br /> NAME OF APPLICANT(print) 426. TITLE OP APP'LlICANT 427. <br /> Tom Piskor(Agent for Shell Oil Products) Project 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(1199)-112 http://www.unidoes.org Rev.02/16/00 <br />