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mer <br /> IED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Pare of <br /> TWE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ''- -7_PEHirfANENI'CY E{'08E <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only 'A❑ 8.TANK REMOVED \ <br /> ❑6 TEMPORARY SITE CLOSURE s'' 406 <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAMEsome as FACILITY NAME or IDEA-Doing Business Ax) 3 FACILITY Off ,. <br /> Ben-Holt/ 1-5 Shell <br /> 3011 W. Benjamin Holt, Stockton CA 95219 <br /> NER ❑ <br /> NEAREST CROSS STREET 401 FACILITY OWTYPE 4.LOCAL GENCY/DISTRI <br /> 1-5 ® 1.CORPORATION El5.COUNTY AGENCY' �f <br /> BUSINESS 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL El 2.INDIVIDUAL ❑6.STATE AGENCY' 11 q�0 I <br /> TYPE CI 2.DISTRIBUTOR [:]4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.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 /> 3 404 ❑ Yes ® No 405 406 <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Shell Oil Products US 310-816-2027 <br /> MAILING OR STREET ADDRESS 409 <br /> 20945 S.Wilmington Ave. <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> Carson CA 90810 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION UZINDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY <br /> ❑ 3. PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7. FEDERAL 413 <br /> 1IL TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Shell Oil Products US 310-816-2027 <br /> MAILING OR STREET ADDRESS its <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 Lj 4.LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 420 <br /> ❑ 3. PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 0 13 19 0 2 1 6 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ® 1.SELF-INSURED ❑4. SURETY BOND [-17.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 /> 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 1 or 2 is checked. ® 1.FACILITY ❑2. PROPERTY OWNER ❑3.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 /> SIGNATURE OF APPLICDATE 424 PHONE 425 <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(Formcal useonly) 428 1998 UPGRADE CERTIFICATE NUMBER(Forloml useooly) 429 <br /> San Joanuin Coucty.OES RORO <br /> UPCF(1/99 revised) Formerly SWRC3 Form A <br />