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Mok 'AM <br /> ((D'71)R1240--i /-OV-- <br /> UNIFIED PROGRAM CONSOLIDATED FORM 3 A 71e <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> X `FAQ <br /> TOTAL NUMBER OF USTs AT FACILITY 4o4' FACILITY ID# /1 /F <br /> 2 (Agency Use Only) IF IT t 1`16 <br /> BUSINESS NAME(same as FACILr1Y NAME or DBA-Doing Business As) ��`�-rte 3 <br /> Valle Pacific Petroleum Cardlock-Charter WayC✓ 11 <br /> BUSINESS SITE ADDRESS 103 CITY 1W. <br /> 1501 W Charter Way Stockton <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> OPERTY OWNER NAME PHONE 408 <br /> Valley Pacific Petroleum Services,Inc 209 948-9412 <br /> MAILING ADDRESS 409. <br /> 188 A Frank West Circle <br /> CITY 410. STATE 411 ZIP CODE 41z. <br /> Stockton CA 95206 <br /> TANK OPERATOR NAME 428-1 PHONE 428.2 <br /> Valley Pacific Petroleum Services,Inc <br /> ( 209 ) 948-9412 <br /> MAILING ADDRESS 428-3 <br /> 188 A Frank West Circle <br /> CITY 4284 STATE 429-5 ZIP CODE 428.6 <br /> Stockton CA 95206 <br /> , <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. ZIP CODE 419 <br /> Stockton CA 95206 <br /> OWNER TYPE: ❑ 4.LOCAL AGFNCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> TY(TK)HQ 44- 10 2 4' 1 9 1 5 3 Call the Stene Bmd of EgWi7at an,Fud TM Division,if there are questions. sz1. <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER. ® 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> CERTIFICATION: I cert*that the information provided herein b aecara M and in fall compliance with Iftal requirements. <br /> APPLICANT SIGNATUR✓E,i7jr� DATE 424 PHONE 425 , <br /> 3/23/2009 <br /> 209 993-8793 �- <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Mike Eliason Cardlock Manager ,:., <br /> UPCF UST-A Rev.(12/2007) ..-.. <br /> �, <br /> � ��� <br /> i wJ <br />