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FIED PROGRAM CONSOLIDATED FORM <br /> IM <br /> TANKS <br /> UNDERGROUND STORAGE TANKS -RCILITY <br /> (One page per site) Page 1 of 9 <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 40(I. <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 /> 99 Shell ID# I. <br /> NEAREST CROSS STREET 401, FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> HWY 99 ® 1.CORPORATION [15.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5.COMMERCIAL 403• ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.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 /> 4 ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. 1 PHONE 408. <br /> Shell Oil Products C/O Bill Merchant 916-684-6125 <br /> MAILING OR STREET ADDRESS <br /> 409. <br /> 9141 East Stockton Blvd, Suite 250-321 <br /> CITY 417 STATE 411. 1 ZIP CODE 412 <br /> Elk Grove CA 95747 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Shell Oil Products C/O Bill Merchant 925-766-3498 <br /> MAILING OR STREET ADDRESS 416. <br /> 9141 East Stockton Blvd, Suite 250-321 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Elk Grove CA 1 95747 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420. <br /> ❑3.PARTNERSHIP [:15.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 0 3 1 9 1 0 1 2 1 6-T Call 916 322-9669 if questions arise 421. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ®1.SELF-INSURED [14.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ❑3.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 1 or 2 is checked. ❑ 1.FACILITY [12. 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 0, PLICANT DATE 424. <br /> PHONE 425. <br /> 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 use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />