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FROM (WED)AUG 30 2006 1a8/ST. 17,33/No. 6843597301 P 3 <br /> UNIFIED PROGRAM(UP)FORM <br /> UNDERGROUND STORAGE TANKS - FACILITYAlp,, <br /> /orP viO <br /> one site 1 of 1 <br /> TYPE OF ACTION ®1.NEW SITE PERMIT C)3.RENEWAL PERMIT E3 S.CHANGE OF INFORMATION 0 TPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑2.INTERIM PERMIT ❑4.AMENDED PERMIT ❑&TEMPORARY SITE CLOSURE ❑ S.TANK REMOVED 400 <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS'NAME(Swne as FACILITY runti=ar DBA) a FACILITY ID# <br /> valley Pacific Pe eu Services Inc. ?6�U <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE Q <br /> .,4,LOCAL AGENCYIDISTRICTw <br /> Car 1791 <br /> ter Road ® 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION El 3. FARM U 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ®2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP 1717,FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS is facility on Indian Re6erva6on or 'If owner of UST In a publlcegoroy:creme or aupervieor of division,section or <br /> REMAININGA;SITE trustlands7 office which operates the LIST(Thin k Bis oordaot person for the tank fMrdG) <br /> I�i a09 ❑ Yes ® No 405 406 <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAMEuV } CA.}-��j�rr407 PHONE 409 <br /> e 1-209-914-3386 <br /> MAILING OR STREET ADDRESS <br /> 409 <br /> P.O.Box 4986- <br /> CITY 410TATE 411 ZIP CODE 412 <br /> _Tmoro ILi CA 96378 <br /> PROPERTY OWNER TYPE Ell.CORPORATION 02.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT 06,STATEAGENCY <br /> ®3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7,FEDERAL AGENCY ala <br /> 111.TANK OWNER INFORMATION <br /> TANKOWNERNAME ata PHONE 415 <br /> Valle Pacific Petroleum Services Inc 1-209-948-9412 <br /> MAILING OR STREET ADDRESS 416 <br /> 188A Frank West Circle <br /> CITY ate I ZIP CODE 419 <br /> Stockton CA 95206 <br /> TANKOWNERTYPE NI.CORPORATION U2.INDIVIDUAL 4.LOCAL AGENCY I DISTRICT L16.STATEAGENCY 420 <br /> ❑3.PARTNERSHIP CIS.COUNTY AGENCY 0 7,FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HO - Call 916 322-9669 ff uestions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE <br /> METHONs) L31-SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT 0 B,STATE FUND&CFO LETTER ❑ 99.OTHER:_ <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one boa to Indkale which address should be used for legal notmosa"end molling. <br /> Legal notificaflors and molWgs will be sent(o fie lank owner unless box 1 or 2 le checked. ❑ 1.FACILITY E3 2. PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-I cer*that the Information provklm her lrtle and accurate to Ow best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 1 PHONE a25 <br /> NAME OF APPLICANT Wrt) a TI E OF APPLICANT 427 <br /> Mike Ellason Cardlock Manager <br /> OFFICIAL USE ONLY DATE RECEIVED COPA PA DISTRICTIINSPECTOR <br /> STATE UST FACILITY NUMBER 42e I 1998 UPGRADE CERTIFICATE NUMBER 429 <br /> UP FORM(1/2000 Version) 1 <br /> Formerly SWRCB Form A <br /> SBC u57•A.doc <br />