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IFIED PROGRAM CONSOLIDATED FOR PR N; 4 FAC k: UNDERGROUND STORAGE TANKS - FACILITY a qlD (one page per siti),01! TYPE OFACTION ❑ U NEW SITE PERMIT ❑ 3.RENEWAL PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE (Check one item only) ❑ 4,AMENDED PERMIT durst low,um mN - El 8.TANK REMOVED El6.TEMPORARY SITE CLOSURE Orn I.FACILITY/SITE INFORMATION 3550 S HWY 99 STOCKTON BUSINESS NAMES.u FACILITY NAME or DRA-Doing Ban.As) 3 F [TOV_I N RIDp U U o30 os82� , NEARESTCROSSSTREET 1I (x,,I' FACILITY OWNER TYPE t�rly0 �I�V} 'V f�`401 El 1.CORPORATION ❑4.LOCALY AGENCY- BUSINESS BUSINESS I.GAS STATION ❑ 3.FARM _/ (/ ❑ 2.INDIVIDUAL ❑ 5.COUNTY AGENCY' TYPE ❑ 5.COMMERCIAL ❑6.STATE AGENCY- 2.DISTRIBUTOR ❑ 4.PROCESSOR ❑6.OTHER 409 ❑3.PARTNERSHIP 402 ❑ 7.FEDERAL AGENCY' TOTAL FIUMB R OF TANKS Is facility on Indian Reservation or REMAINING AT SITE trusllands? 'Ifowner of UST is a public agency:time ofsupervisor ofdivision,ace ion or office which operates the UST(This is the contact person for the tank records) aa4 ❑ Yes ® No 405 4% 11.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407 PHONE �1 nq- N- ;^�L4 "s t Pmd( YV11 8 ( 5 MAILING OR STREET ADDRESS "-" &. " "-W .0 0 6 409 CITY 410 STATE 411 ZIPCODE a12 S�Af�T9N-� Iac CA PROPERTY OWNER TYPE EJ LCORPORATION ❑ 2.INDIVIDUAL [_1 4.LOCAL AGENCY/DISTRICT El 6.STATE AGENCY *P3.PARTNERSHIP 115.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 416 PHONE .115 VALLEY PACIFIC PETROLEUM-RAPID 209 948-9412 MAILING OR STREET ADDRESS }S'J Y-9 � 1 �I r 416 _CITY 417 STATE 419 ZIP CODE STOCKTON CA S' 7 6 19 TANKOWNERTYPE 1.CORPORATION 02.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT El 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- Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED 1:14.SURETY BOND .��❑{{{,,, 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT 8.STATE FUND&CFO LETTER %❑99.OTHER ❑3.INSURANCE ❑6.EXEMPTION .Lr] 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. _,„__,_ _ m�emu F-1 2.PROPERTY OWNER 1P 3.TANK OWNER 423 Legal notifications and mailing will be seat tothe tank owner unless box I or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best ofmy knowledge. SIGNATURE OF APPLICANT DATE 424 PHONE 425 NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 STATE UST FACILITY FIUMBER(Forlo:al wenh.) 428 1 1998 UPGRADE CERTIFICATE NUMBER(Forl«alauonl.) 429 Is 1998 Compliant? UPCF(1/99 revised)