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IFIED PROGRAM CONSOLIDATED FOR* PR#:PRO231580 FAC#:FA0003963 UNDERGROUND STORAGE TANKS - FACILITY (one page per site) TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑ 3.RENEWALPERMIT ❑ 5.CHANGE OF INFORMATION (Ch«k one item only) ❑ Z PERMANENTLY CLOSED SITE ❑ 4.AMENDED PERMITslai[v hang loW uxcdY „;. =9R ElB.TANK REMOVED ❑6.TEMPORARYSITE CLOSURE 460 1.FACILITY/SITE INFORMATION 2420 W GRANT LINE RD,TRACY BUSINESS NAME(S.as FACILITY NAME or DBA-Doing Business An FACILITYID# I PR ID# GRANT LINE VALERO FA0003963 PR0231580 1 NEAREST CROSS STREET FACILITY OWNER TYPE GRANT LINE 401 ® I.CORPORATION ❑4.LOCAL Y AGENCY- BUSINESS BUSINESS I.GASSTATION ❑ 2.INDIVIDUAL ❑ S.COUNTY AGENCY' TYPE ❑ ❑ 3.FARM 5.COMMERCIAL ❑ 6.STATE AGENCY" ❑2.DISTRIBUTOR ❑ 4.PROCESSOR ❑6.OTHER 403 ❑ 3.PARTNERSHIP El 7.].FEDERAL AGENCY" TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public REMAINING AT SITE trustlands� P agency:name took r e olds.of division,section or Office which operates the UST(This is the contact person for the nude records.) 464 ❑ Yes ® No 409 MINHAS,ROSHAN S 606 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 46] PHONE 408 TOSTE FARMS INC 209 8I3I5!,4476 2480 MAISTREET ADDRESS l C� l' �� 409 2480 TOSL RD QS CITY 416 STATE 411 ZIP CODE J12 TRACY CA 95376 PROPERTY OWNER TYPE ❑ 1.CORPORATION M 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [:16.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY [17.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANKOWNERNAME 414 PHONE 415 CALIFORNIA GAS STATION LLC (209)835-4476 MAILING OR STREET ADDRESS 2 2420 W GRANT LINE RD 416 CITY 417 STATE 416 ZIP CODE 419 Same As Site Same As Site Same As Site TANK OWNER TYPE ❑ 1.CORPORATION © 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY TANK OPERATOR INFORMATION TANK OPERATOR NAME TANK OPERATOR TITLE ROSHAN S MINHAS PARTNER IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44-7E44--035131 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ L SELF-INSURED 1:14.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ZI 99.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 M 2.PROPERTY OWNER ❑3.TANK OWNER 423 Legal notifications and mailing will be sem to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 421 STATE UST FACILITY NUMBER(For local uc ooly) 428 1998 UPGRADE CERTIFICATE NUMBER(Forinealuaody) 420 Is 1998 Compliant?Y UPCF(1/99 revised)