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UNIFIED PROGRAM CONSOLIDATED FORM <br />` TANKS <br />2I <br />UNDERGROUND STORAGE TANKS - FACILIT (/ l <br />177"el) <br />� .�7 <br />0- <br />(one page per Page of <br />TYPE OF ACTION Lj 1. NEW SITE PERMIT 3. RENEWAL PERMIT X S.CHANGE OF INFORMATION LTPERMANENTLY CLOSED SITE <br />(Check one item only) 4. AMENDED PERMIT specify change local use only n & TANK REMOVED <br />❑ 6.TEMPORARY SITE CLOSURE 400 <br />10 S G� -rr � A 1-1-1 0 k 1. FACILITY/ SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As)g <br />QuickStuff 97789 <br />il;� <br />FA <br />01 j <br />737 <br />NEAREST CROSS STREET 401 <br />FACILI WINER TYPE <br />U(.AL AULN(-Y/DIS 11 <br />8 Mile/ 1-5 <br />❑x 1. CORPORATION 5. COUNTY AGENCY* <br />❑ 2. INDIVIDUAL 6. STATE AGENCY* <br />BUSINESS X <br />TYPE F-1 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 403 <br />❑ 3. PARTNERSHIP 7. FEDERAL AGENCY* 402 <br />TOTAL NUMBER OF I ANKS <br />Is tacility on Indian Reservation or <br />owner of U51 Is a public agency: name or supervisor ot division, section or ottice which <br />REMAINING AT SITE <br />trustlands? <br />operates the UST (This is the contact person for the tank records.) <br />2 404 <br />❑ Yes ❑x No 405 <br />406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 408 <br />Jack in the Box, Inc. <br />(858)571-2689 <br />MAILING OR STREET ADDRESS 409 <br />9330 Balboa Avenue <br />CITY 2117- <br />SIAIL <br />ODE 412 <br />San Diego <br />CA <br />92123 <br />PROPERTY OWNER I YPL x <br />E] 3. PARTNERSHIP ❑ S. COUNTY AGENCY 7. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414ONE <br />415 <br />Jack in the Box c/o JMM Management Group <br />(847) 888-0276 <br />MAILIN6 OR STREET ADDRESS 410 <br />2496 Technology Drive <br />CITY 417 <br />STATE 418 ZIP CODE 419 <br />Elgin <br />11 60124 <br />IX420 <br />3. PARTNERSHIP 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />3 8 1 9 6 1 2 Call (916) 322-9669it questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) I.SELF-INSURED ❑ 4. SURETY BOND 7. STATE FUND 10. LOCAL GOVT MECHANISM <br />GUARANTEE ❑ 5. LETTER OF CREDIT 8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />3. INSURANCE ❑ 6. EXEMPTION E] 9. STATE FUND & CD 422 <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should a used for legal notifications and mailing. Legal <br />notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER Z 3. TANK OWNER 423 <br />VII. APPLICANT SIGNATURE <br />Certification - I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNA-FUJLE OF APPLICANT <br />DATE 424 <br />09/27/07 <br />425 <br />(847) 888-0276 <br />NAME: OF APPLICAN I print <br />Daniel A Erickson <br />Compliance Manager <br />11 STATE UST FACILITY NUMBER (For local use only) <br />1 (For local use only) <br />UPCF (1/99 revised) 8 Formerly SWRCB Form A <br />