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QNIFIED PROGRAM CONSOLIDATED FOR PR JFA FAC UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPEOFACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT SCBANGE OF INFORMATION ].PERMANENTLY CLOSED (Check one item only) ❑ ❑ ❑ 4.AMENDED PERMIT ❑ 8.TANK REMOVED ❑b.TEMPORARY SITE CLOSURE 400 1.FACILITY/SITE INFORMATION 3550 S HWY 99,STOCKTON BUSINESS NAMEtsaanm FACILITYNAME«DRA-DOIngimssaa AS) 3 FACILITY IDN PR IDN VPPS 1004 F1!001 7030 PR050582I 1 NEAREST CROSS STREET FACILITY OWNER TYPE HWY 99 401 ® 1.CORPORATION [:1 4 LOCAL AGENCY/DISTRICT- BUSINESS ® 2 GAS STATION ❑ 3.FARM ❑ 5.COMMERCW, ❑2.MDMDUAL El 5.COUNTY AGENCY- TYPE ❑2 DISTRIBUTOR PARTNERSHIP C:] 6.STATE AGENCY' ❑4.PROCESSOR ❑b.OTHER 403 3❑ P ❑ ].FEDERAL AGENCY- 401 TOTAL NUMBER OF TANKS Is faciliublic ty on Indian Reservation or +!£owner of UST is n REMAINING AT SITE trustlands? P age cy:name of supervisor of division,section or office which operates the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 405 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 401 PHONE :::;I ® 408 w f MAILING OR STREET ADDRESS a09 (3L) SS2H2. CITY 410 I STATE 411 ZIPCODE 412 -_TR ea - CA 95398 S�2/a PROPERTY OWNER TY PE _XI CORPORATION 112.INDIVIDUAL 114.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY /` -993.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 VALLEY PACIFIC PETROLEUM SER INC 209 948-9412 MAILING OR STREET ADDRESS 188A FRANK WEST CIRCLE 416 CITY 4I] STATE 41e 1 ZIP CODE 419 STOCKTON CA 95206 TANK OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL - ❑ 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ I SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ® 8.STATE FUND&CFO LETTER ©99.OTHER 1:13.INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used fm legal notifications and mailing, ❑ I FACILITY M 2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked, VII.APPLICANT SIGNATURE Certification-1 canary that the information provided herein is tone and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 4zs (209)481-3342 NAsV1E OF APPLICANT(print) 426 TITLE OF APPLICANT 4n MIKE ELIASON CARDLOCK MANAGER STATE UST FACILITY NUMBER F.local ce anly) 428 1998 UPGRADE CERTIFICATE NUMBER(Fix 1.1 moomly) 429 Is 1998 Compliant?Y UPCF(1/99 revised)