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VIFIED PROGRAM CONSOLIDATED FOR PR#:PR0231580 FAC#:FA0003963 UNDERGROUND STORAGE TANKS -FACILITY (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4.AMENDED PERMIT qne fv d1ange local use only ❑ 8.TANK REMOVED ❑6. 1 F%IPOIZ.ARY s ri:CLOst1R1' 400 I.FACILITY/SITE INFORMATION 2420 W GRANT LINE RD,TRACY BUSINESS NAME(same as FACB.rrY NAME or DBA-Doing Susinms As) 7 FACILITY ID# I PR ID# T� GRANT LINE VALERO FA0003963 PR0231580 1 NEAREST CROSS STREET F_ACJI ITY OWNER TYPE 401 �J•�f ❑ 4.LOCAL AGENCY/DISTRICT- GRANT LINE 1.CORPORATION ❑ S.COUNTY AGENCY' BUSINESS 1,GAS STATION ❑3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL ❑ 6.STATE AGENCY* TYPE ❑ 3.PARTNERSHIP 402 ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 407 ❑ 7.FEDERAL AGENCY* TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes ® No 405 406 II.PROPERTY OWNER INFORMATION P OWMR N 407 PHONE Z0`I 7 2- 408 i 3 rCJIT �-�-C - LIN DRES 409 �yz - Cz CIT � 410 STATE ,� 41 l ZIP CODE 412 53 -FR-05PEAIZOWNER TYPE ❑ 1.CORPORATION ® 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 1 ala PHONE 2-04-g g21? 41, 70_STFTMe4&4NC Sc..q-- A c S'*,;�x� \ 0,4 Ute.C_ MAILING OR STREET ADDRESS r 416 2 kAZo CITY 417 STATE 418 ZIP CODE 419 TRACY ��tt CA 195376 TANK OWNER TYPE 1.CORPORATION •IliJ 2.INDIVIDUAL 1:14.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44_-� Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT k8.STATE FUND&CFO LETTER 19199.OTHER ❑3.INSURANCE ❑ 6.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. ® 1.FACILITY ❑2.PROPERTY OWNER ❑3.TANK OWNER 427 Legal notifications and mailing will be sent 10 the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-1 certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 s - 4 'ts-- 1%- v�► �� - X32' g z�3 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 rATEUSTFACILITYNUMBER(Forlocalueonly) 428 1998UPGRAD TIFICATENUM13ER(Forlomluseonly) 429 Is 1998 Compliant?Y UPCF(1/99 revised)