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UN ED PROGRAM CONSOLIDATED F <br /> ..., Dl l JUN 11 2002 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY SK+ "Ai`Y <br /> U afEEOFE*RSENC *WS#a) <br /> TYPE one item ACTION <br /> (Check onj' 1.NEW SITE PERMIT X 3.RENEWAL PERMIT r 5.CHANGE OF INFORMATION(Specify Mange- r 7.PERMANENTLY CLOSED SITE <br /> only) <br /> r 2.NEW OPERATOR r 4.AMENDED PERMIT local use only) r 8.TANK REMOVED 400 <br /> F 6.TEMPORARY SITE CLOSURE <br /> 1.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 <br /> Ben Holt/1-5 Shell, John Kendrick <br /> 3011 W. Benjamin Holt, Stockton, CA 95219 I <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r 4. LOCAL AGENCYIDISTRICT' <br /> X 1. CORPORATION r & COUNTY AGENCY- <br /> BUSINESS TYPEr 2. INDIVIDUAL r6. STATE AGENCY- <br /> X 1.GAS STATION IF 3.FARM r 5.COMMERCIAL r 3. PARTNERSHIP <br /> F 2.DISTRIBUTOR r 4.PROCESSOR r 6 OTHER r 7 FEDERALAGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a Public agency:name of supervisor of <br /> REMAINING AT SITE husbands? division,section or once which operates Ne UST. <br /> This is the contact person for the tank records.) <br /> 404 3 r Yes X No 405 406 <br /> Il.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> SHELL OIL PRODUCTS US C/O Bruce T. Marubashi,.H,S&E Analyst 925-766-3498 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. BOX 8509 <br /> CITY 410STATE 411 ZIP CODE 412 <br /> SANJOSE CA 95155 <br /> PROPERTY OWNER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 413 <br /> X 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTYAGENCY r 7. FEDERALAGENCY <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> SAME AS 11 <br /> MAILING OR STREET ADDRESS 416 <br /> CITY 417 STATE 418 ZIPCODE 419 <br /> TANK OWMER TYPE r 2. INDIVIDUAL r 4. LOCAL AGENCY/DISTRICT r 6. STATE AGENCY 420 <br /> F 1. CORPORATION r 3. PARTNERSHIP r 5. COUNTY AGENCY r 7. FEDERALAGENCY <br /> TY(TK)HQ 4 4 1 - 3191012161 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) X 1. SELF-INSURED r 4. SURETY BOND r 7. STATE FUND r 10. LOCAL GOV=T MECHANISM <br /> r 2. GUARANTEE r 5. LETTER OF CREDIT r S. STATE FUND&CFO LETTER r 99. OTHER' <br /> r 3. INSURANCE r 6. EXEMPTION r 9. STATE FUND&CD 422 <br /> Check one box to Indicate which address should be used for legal nol8icatmns and mailing. X 1. FACILITY r 2. PROPERTYOWNER r 3. TANKOWMER 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification. I candy that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNAT OF APPLICAN DATE 424 1 PHONE <br /> 617/02 925-766-3498 425 <br /> NAME OF APPLICANT(print) TITLE OF APPLICANT 427 <br /> BRUCE T. MARUBASHI for Shell Oil Products US 426 H,S&E Analyst <br /> STATE UST FACILITY NUMBER(Forlocal use only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />