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UNIFIED PROGRAM(UP)FORM UNDERGROUND STORAGE TANKS - FACILITY one e r site P e 1 of 1 TYPE OF ACTION 0 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CRANGE OF INFORMATION ❑ 7_PERMANENTLY CLOSED SITE (Check one item only) [12,INTERIM PEfW rr [14.AMENDED PERMIT ❑&TEMPORARY SITE CLOSURE ❑ S.TANK REMOVED 400 I. FACILITY f SITE INFORMATION S 7 FlZ ES J BUSIMESS NAME(Same asFACIITYNAhiEcrDBA) 3 1 FACILITY IDI{ 7 � � 1 Valle Pacific Petroleum Services,Inc. NEAREST CROSS STREET 401 FACILITY OWNER TYPE 4.LOCAL AGENCYIDISTRICT* Charter Way CD 1.CORPORATION ❑5.COUNTY AGENCY' BUSINESS ❑1.GAS STATION 3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' TYPE 2.DISTRIBUTOR ❑4 PROCESSOR❑6. OTHER d03 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' ace TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If ownerof UST is a public agency:name of super w of division,section or REMAINING AT SITE t ustlaads? ofRce which operates the UST(Thie Is the contacl person for the tank rec«ds_) 1 404 ❑ Yes ID No Q5 4aa N M 11. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 pyONE 4os Valle Pacific Petroleum Servioes,INC 1-2D9-948-9412 N M MAILING OR STREET ADDRESS , 09 cn 0 188A Frank West Circle z CITY 410 STATE411 ZIP CODE 412 Stockton CA 95206 PROPERTY OWNER TYPE 1.CORPORATION ED 2.INDIVIDUAL Cj 4.LOCAL AGENCY 1 DISTRICT 6.STATE AGENCY M ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY 413 111.TANK OWNER INFORMATION TANK OWNER NAME 444 PHONE ala Valley Pacific Petroleum Services, INC 1-20-948-9412 MAILING OR STREET ADDRESS 416 N 188A Frank West Circle CD CD CITY 417 STATE 418 ZIP CODE 419 `�' Stockton CA 952D6 00 TANK OWNER TYPE 1.CORPORATION 0 2.INDIVIDUAL 0 4.LOCAL AGENCY I DISTRICT ❑6.STATE AGENCY 420 E13-PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER o TY JK)HQ - Call 916 322-9669 if questions arise 421 V. PETROLEUM UST FINANCIIAL RESPONSIBILITY INDICATE METHOD(s) ❑1.SELF-INSUREO ❑4.SURETY BOND ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ®S.STATE FUND&CFO LETTER ❑ 99.OTHER: [13.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 VI. LEGAL NOTIFICATION AND MAILING ADDRESS (-heck one Dox m indicate wtrch address should De used for legal notrricatiwcs and mailing. 423 Legal notficabons and malrulgs will tie sent to the tank owner uNess bon 1 or 2 is checked. i] 1.FACILITY ❑2 PROPERTY OWNER ®3_TANK OWNER VII.APPLICANT SIGNATURE Certification-I ce l ty that the IrlfOrmabOn pr Ir"i ' true and aomrate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT( W) 426 TITLE OF APPLICANT 427 S Mike Eliason Cardlock Manager OFFICIAL USE ONLY DATE RECEIVED COPA PA DISTRICTANSPECTOR STATE UST FACILITY NUMBER 428 1998 UPGRADE CERTIFICATE NUMBER 4?9 UP FORM(112000 Version) 1 Formerly SWRCB Form A SBC UST-A.doc 0