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U ED PROGRAM CONSOLIDATED FORTS <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE O;i�te�m <br /> ON ❑ I.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check oly) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> � 9 1 �d v d� X i�:sa rr t(`.,ySt t� �F}��a•! �. ,, ti, .0 - .f t r^, a !d - '!a(��ti4 ,J w .1 ( v t <br /> `�"•[ , 3�'^+�{M� f}�� ,t,�v ai !N Y�x st y�r1E"� �t t.';'� !Y FACILITY INFORMATION ` � t � � � . <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY(D# <br /> 4 (Agency Use On <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> TIZAC­f 61\/D1+F_ -L- <br /> BUSINESS SITE ADDRESS 103, CITY 104. <br /> 3725 N.Tracy Boulevard Trac <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> yydP4'^•u.; 'kF aS:',_ ry. iit.,erF: <br /> "t} A P Y •� W y ,'- nl�y�r w 4 ! 1:{r X <br /> CF � ydKY II'g=IPROPERTY OWNER INFORMATIO�tti <br /> 1..h re..:i}i},, t 2'HN'^•Sr k 4x.fY tuF :.?" ..dv: as tt i ..4 <t A. 5� ..?, t(.. .A� ,{ `' ,Y,'•+ <br /> PROPERTY OWNER NAME 407. PHONE. 408 <br /> Equilon Enterprises LLC/Shell Oil Products US (310) 816-2207 <br /> MAILING ADDRESS 409' <br /> 12700 Northborough Dr. <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Houston TX 77067 <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 4284 STATE 428-5 ZIP CODE 428-6 <br /> Castro Valley CA 94546 <br /> N TANK OWNER INFORMATION �,. <br /> TANK OWNER NAME 414 PHONE 415. <br /> E uilon Enterprises LLC I Shell Oil Products US (310) 816-2207 <br /> MAILING ADDRESS 416' <br /> 12700 Northborough Dr. <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Houston TX 77067 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> r <br /> V i BOARD kO �EQITALIZAT�ON�IJST,STORAGE;FEE�ACCOUNT NTI�YIBER %,1 �I <br /> e d.. l... .ter r <br /> TY(TK)HQ 44- 0 3 9 0 2 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 /> y rN F r t ';•4', ». -{ t i^Y�„s�e r. ;sq.+ .; - -T <br /> 7t�' ,'T <br /> IICANTIG'�)`T TITRE g <br /> k ..31 r, ?rt6- f <br /> CE IC T : I certify tha the in ordation provided herein is true,accurate,and in full compliance with legal requirements. <br /> LICAN I R DATE 424 PHONE 4z5. <br /> 9LQ�-1/ w- 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 />