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t <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK i Q wt' <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID# )' <br /> I (dgencv Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> Valley Pacific Petroleum-Fresno Ave Cardlock <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1524 Fresno Ave Stockton <br /> FACILITY TYPE ® L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the racility located on Indian Reservation or 405. <br /> 3.FARM 0 4.PROCESSOR 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408, <br /> Valley Pacific Petroleum Services Inc. 209 ) 948-9412 <br /> MAILING ADDRESS 409. <br /> 198 A Frank West Circle <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Stockton CA 95206 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Valley Pacific Petroleum Services Inc. (209 ) 948-9412 <br /> MAILING ADDRESS 428-3 <br /> 198 A Frank West Circle <br /> CITY 428-1 STATE 428-5 ZIP CODE 428-6 <br /> Stockton CA 95206 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Valley Pacific Petroleum Services Inc. (209 ) 948-9412 <br /> MAILING ADDRESS 416. <br /> 188 A Frank West Circle <br /> CITY 417. 1 STATE 418. ZIPCODE 419. <br /> Stockton CA 95206 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 1 4 5 4 1 1 $ 1 Call the State Board or Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ® 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that t inforp4tion provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE',,,01 % DATE 424. PHONE +S <br /> 7/30/2010 209 993-8793 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE `427 <br /> Mike Eliason Cardlock Manager _ <br /> UPCF UST-A Rev.(12/2007) <br /> 0 <br />