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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <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 Odl. <br /> (Chmkom iu only) ❑ 3,RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE 0 9.TRANSFER PERMIT <br /> 1. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY401' FACILITY ID p _ <br /> 2 (Agaeuy uae oatyJ p <br /> BUSINESS NAME(s..w.,FACa.rN NAamor DBA-odea n.a Ao <br /> Vft Pacific Petroleum Cardlock-Shane and Daves 2 O <br /> v <br /> BUSINESS SITE ADDRESS re' CITY Int. <br /> 3550 S Hwy99 Stockton <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING_ -MVwnacft�Indian Reservation or °05' <br /> ESSOR 6.OTHER Trost lands? ❑Yes <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME J11 PHONE 408. <br /> W& R Enterprises dba Shane and Doves 209 601.6457 <br /> MAILING ADDRESS <br /> P.O.Bo:55242 <br /> CITY 410 STATE 411 ZIP CODE 4b. <br /> Stockton CA 95205 <br /> ION . <br /> TANK OPERATOR NAME +29-1 PHONE 4�2 <br /> Valley Pacific Petroleum Services,Inc ( 209 ) 948-9412 <br /> MAILING ADDRESS 4} 3 <br /> 188 A Frank West Circle <br /> CITY 4� STATE 4as ZIP CODE 4� <br /> Stockton CA 95206 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414_ PHONE n5. <br /> Valley Pacific Petroleum Services,Inc ( 209 ) 948-9412 <br /> MAILING ADDRESS 016 <br /> 188 A Frank West Circle <br /> CITY Orr, 1 STATE 418. ZIP CODE 4M <br /> Stockton CA 95206 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 090. <br /> ❑ 7.FEDERAL AGENCY ® 9.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STURAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 1 3 1 7 1 1 1 9 1 8 1 Call the State Board ofEqualivadon,Fuel Tax Division,if there are questions. 411- <br /> VL PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ® 4.TANK OPERATOR 633 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 40a <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the info tion provided herein is true accurate and in full compliance with legal requirement& <br /> APPLICANT SIGNATUREDATE Jai- PHONE 4u. <br /> 3/23/2009 z04 993-8793 ry <br /> APPLICANT NAME(print) 4t6. APPLICANT TITLE °n `CL* <br /> Mike Ellmmn Cardlock Manager <br /> r <br /> r <br /> UPCF UST-A Rev.(1712007) <br />