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FIED PROGRAM CONSOLIDATED FOQJ f- �Z <br /> TANKS a/?o%5/ <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) Page I 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 DBA-Doing Business M)----3. FFACILITY <br /> ID# t. <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 4027 <br /> Country Club Shell,2575 Country Club Blvd., Stockton ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS® 1.GAS STATION [13.FARM ❑5.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR ❑6.OTHER ❑3.PARTNERSHIP ❑7.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 /> 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 E. Stockton Blvd.,Suite 250-321 <br /> CITY 410. STATE 411. <br /> ZIP CODE 412• <br /> Elk'Grove CA 95624 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑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,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 [:12.INDIVIDUAL ❑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- 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) 19 1.SELF-INSURED ❑4.SURETY BOND [17.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 I 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 PPLICANT DATE 424• 1 PHONE 425• <br /> o� H.r- 6;<- S A&U- &(,//7/041 916.631.1300 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 />