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-^U FIED PROGRAM CONSOLIDATED FORM (Z` <br /> UNDERGROUND STORAGE TANK �(� 7j <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMAM( <br /> TYPE OF ACTION ❑ 1.NEW PERMIT' ® 5.CHANGE OF INFORMATION [17.PERMANENT FACrL CrCLGSURE <br /> (Check use hem°Oty) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT MAR 2 3 2011 <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTS AT FACILITY FACILffYm# _ - 1 1 M /P R <br /> 2 (Agency Use Only) <br /> BUSINESS NAME(sun u FAculry NAME.DBA-Dom,taumna A:) 5. <br /> Circle K Stores, No 2701205 <br /> BUSINESS SITE ADDRESS 103. CITY IOi. <br /> 16470 Cambridge I Lathrop <br /> FACILnY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation m 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME4a'1. PHONE <br /> Khinda, Hardell & Amarjit Singh Khinda Attn: Hardev Khinda 209-321-1632 <br /> MAILING ADDRESS 4w. <br /> 27000 S. Leeward Way <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Tracy CA 95304 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME <br /> Circle K Stores, Inc. (951) 270.51 U8 <br /> MAILING ADDRESS 42&3 <br /> 155 East Rincon, Suite 1cO <br /> CITY 628'4 STATE 423� <br /> Corona CA 192879 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 PHONE 415, <br /> Circle K Stores, Inc. (951) 270-51M <br /> MAILING ADDRESS 416' <br /> '5 East Rincon, Suite 1 of <br /> CnY 411. STATE 41e, ZIP CODE 419. <br /> Corona CA 92879 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 42.. <br /> ❑ 7.FEDERAL AGENCY ® &NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 13 12 10 1 7 1 3 Call the State Board of Equalization,Fuel Tax Division,if then ate questions, al' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ® 4.TANK OPERATOR 4-3 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requited For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information Provided herein is true,accurate,and in full compliance with legal requirements. <br /> IC IG IRP DATE 3I143�1\ 4u. PHONE(951) 270-5108 4M. <br /> �YPLICANT N prim) I v 4x. APPLICANT TITLE 92t <br /> 3 lex d0.�A4S� Environmental Compliance Manager <br /> UPCF UST-A Rev.(122007) <br />