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FROM (WEN AUG 30 2006 1 8/3T, 17:33/No. 6843597301 P 3 <br /> UNIFIED PROGRAM(UP)PORIA <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> one site) Pa a 1 of 1 <br /> TYPE OF ACTION 0 1.NEW SITE PERMIT 0 3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATIOfI <br /> ❑ 7.PEItMAafENTLY CLOSED SI <br /> (Check one item only) ❑2.INTERIM PERMIT ❑d.AMENDED PERMIT ❑6.TEMPORARY SITE CLOSURE 13a.TANK REMOVED 400 <br /> I. FACILITY I SITE INFORMATION <br /> BUSINESS NAME(WM M MUFLJ NA a 06A) 3I FACILITY ID# <br /> Valle Pacific PeV sum Services Inc. <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE 4.LOCAL AGENCYIOISTRICT <br /> Car nter Road 0 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION 3.FARM 5. COMMERCIAL ❑ 2.INDIVIDUAL [16-STATE AGENCY' <br /> TYPE ®2.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 ❑ 3.PARTNERSHIP [17.FEDERAL AGENCY' <br /> 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST la a public aWMT-mms of auperviam ddiviaion,Section or <br /> REMAINING AT SITE trusbands7 Office which Operates the UST Crhis is ft txnlad Person fp aM tank record&) <br /> 2 404 ❑ Yes ® No 405 <br /> ao6 <br /> If. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE we <br /> Mile Padilla and Hamid Khatlrina 1-209.914 3386 <br /> MAILING OR STREET ADDRESS <br /> P.O. Box 1036 40° <br /> CITY a10 STATE 411 <br /> 21P CODE 412 <br /> Trac CA 95378 <br /> PROPERTY OWNER TYPE 1,CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY!DISTRICT 6.STATE AGENCY <br /> ®3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III.TANK OWNER INFORMATION <br /> 7ANKOWNERNAME 414 1 PHONE 416 <br /> Valle Pac IC Petroleum Services Inc 1-209-948-9412 <br /> MAILING OR STREET ADDRESS 416 <br /> 18M Frank West Circle <br /> CITY 417 STATE 41e 1 ZIP CODE 419 <br /> Stockton CA 95206 <br /> TANK OWNER TYPE 1,CORPORATION 2.INDIVIDUAL 4.LOCAL AGENCY I DISTRICT 6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP 0 5.COUNTY AGENCY ❑7,FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ - Call 916 322-9669 ff questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE <br /> METHOD(s) ❑1_SELF-INSURED ❑4.SURETY BOND Q 7.STATE FUND <br /> [] 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT E3 8.STATE FUND&CFO LETTER ❑ 99.OTHER:_ <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> one bac to IrMlpk which address should be used for kgal rwtld <br /> Legal cadone and malling. <br /> Legal no5aadals and malInP WII be sant to ft tank owner unless box 1 or 21s checked. ❑ 1.FACILITY [12. PROPERTY OWNER C9 TANK OWNER 429 <br /> VII. APPLICANT SIGNATURE <br /> Ceaf teetion-I ce*that the Information Provided her in*and accurate to the bast of my knoW*dge. <br /> SIGNATURE OF APPLICANT DATE 424 <br /> PHONE 426 <br /> NAME OF APPLICANT npg 426 TITLE OF LICAN 7 <br /> Mike Eliason Cardlock Manager <br /> p <br /> USE ONLY DATE RECEIVED COPA PA OISTRICTpNSPECTOR FACILITY NUMBER 428 1998 UPGRADE CERTIFICATE NUMBER 429 <br /> UP FORM(1/2000 Version) 1 Former) SWRCB Form A <br /> SBC UST•A.doo y <br />