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U ED PROGRAM CONSOLIDATED FOR �Q til Z 3/�Q <br /> UNDERGROUND STORAGE TANK !( <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION [:17.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INF'ORtVIATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# t. <br /> 4 (Agency Use Only) l �� <br /> $ _ `A-Doing Business As) 3. <br /> IVN <br /> ESS SITE ADDRESS 103. CITY 104, <br /> 3725 N.Tracy Boulevard Trac <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or aos. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> R NAME 407, PHONE aos. <br /> nterprises LLC/Shell Oil Products US (310) 816-2207 <br /> ING ADDRESS 409. <br /> 12700 Northborou h Dr. <br /> CITY 410. STATE 411. ZIP CODE alz. <br /> Houston TX 77067 <br /> III. TANK.OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> John R. Edwards, Inc. 209-835-7608 <br /> MAILING ADDRESS 428-3 <br /> 3649 Jamison Way <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> Castro Valley CA 94546 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> E uilon Enterprises LLC/Shell Oil Products US (310) 816-2207 <br /> MAILING ADDRESS a16. <br /> 12700 Northborough Dr. <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Mouston TX 77067 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 3 9 0 1 2 1 6 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION , <br /> .. 423 <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT kGNATURE` <br /> CE IC : Y certify that the in orn{ation provided herein is true,accurate,and in full compliance with legal requirements. <br /> LICAN I T R DATE 424. 1 PHONE 425. <br /> 1/5/2010 916-240-1610 <br /> APP ANT AME(print) 426. APPLICANT TITLE 427 <br /> Aura Sibley for Shell OI duct US HS&E Compliance Coordinator <br /> UPCF UST-A Rev.(12/2007) <br />