Laserfiche WebLink
`.. <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ t.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> 400. <br /> (Check one ithn only) ❑ i RENEWAL PERM]I ❑ 6 TEMPORARY FACILITY CLOSURE ❑ 4 TRANSFER PERMIT <br /> 1. FACILITY INFORMATION <br /> "IOIAI. NIIMBEROFIISI,ATFACILII'Y 404. 1' <br /> FACII,F1'Y ID <br /> 2 (Agency Gse Only/ <br /> BUSINESS NAME(Save mFACILI"1 YNAA¢mDBA-Dnmt[B—nevn Ae) <br /> Valley Pacific Petroleum Cardlock-Lodi <br /> BUSINESS SITE ADDRESS 1p3- CITY I00' <br /> 930 E Victor Road Lodi <br /> FACILITY TYPE [5 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 005' <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? []Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME wt. PHONE 4a8. <br /> Valley Pacific Petroleum Services,Inc (l2`0909 <br /> ) 948-9412 <br /> MAILING ADDRESS 4w <br /> 188 A Frank West Circle <br /> CITY 410. 1 STATE 411. ZIP CODE 012 <br /> Stockton CA 95206 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 429'_ <br /> Valley Pacific Petroleum Services,Inc ( 209 ) 948-9412 <br /> MAILING ADDRESS i2N-1 <br /> 188 A Frank West Circle <br /> CITY 429-4 STATE 42x-5 ZIP CODE 428'0 <br /> Stockton CA 95206 <br /> IV. TANK OWNER INFORMATION <br /> IANKOWNERNAME 414- PHONE vs. <br /> Valley Pacific Petroleum Services,Inc ( 209 ) 948-9412 <br /> MAILING ADDRESS 416. <br /> 188 A Frank West Circle <br /> CITY Ort, 1 STATE 418, ZIP CODE 419. <br /> Stockton CA 95206 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY N S.NON-GOVERNMENT' <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)FIQ 44- 0 3 9 4 3 7 Call the Stair Board off+iahianen.Fuel lax Division,if them are questions_ 42L <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue petnut and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ® 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) ms. <br /> VH.APPLICANT SIGNATURE <br /> CERITFICATION: I certify that the inf ar ation provided herein is hve accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 121 <br /> -- 3/20/2012 209 993-8793 <br /> APPLICANT NAM (Pont) 420. APPLICANT I TLE p !;t <br /> Mike Eliason Cardlock Manager T <br /> UPCF UST-A Rev.(12/2007) MAR 2 0 2012 <br />