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' UrWED PROGRAM CONSOLIDATED FORK <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY 3I � <br /> (One page per site) Page 1 of 7 <br /> TYPE OF ACTION [11.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 4i0. <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 /> E.Fremont Shell ID# 1. <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402. <br /> E.Filbert St. ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM [15.COMMERCIAL 403. ❑2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [16.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 ONO <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408. <br /> Shell Oil Products,Attn: Bill Merchant 916-684-6125 <br /> MAILING OR STREET ADDRESS 409. <br /> 9141 E. Stockton Blvd., Suite 250-321 <br /> CITY 410. STATE 411- ZIP CODE 412. <br /> Elk Grove CA 95624 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION [12.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT [16.STATE AGENCY 413. <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Shell Oil Products,Attn: Bill Merchant 916-684-6125 <br /> MAILING OR STREET ADDRESS 416. <br /> 9141 E. Stockton Blvd.,Suite 250-321 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Elk Grove CA 95624 <br /> TANK OWNER TYPE 1.CORPORATION ❑2.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 JK) 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 [14.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE [15.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 [: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 /> SIGNATURE O P CANT /+4`'�T� DATE 424. PHONE 425. <br /> 3 r�� <br /> �-- ,, ��•jd•-� �-v,� SiS��L�� O a4/� 916-631-1300,ext. 19 <br /> NAME OF APPLICANT(print) 426. TITLE OF APPLICANT 427. <br /> Tom Piskor,Agent for Shell Project Manager/Gettler-Ryan,Inc. <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> ( <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidoes.org Rev.02/16/00 <br />