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UJPIED PROGRAM CONSOLIDATED I*M <br /> TANKS nl 2I b 2 <br /> L� UNDERGROUND STORAGE TANKS - FACILITY 4" 81481 <br /> (one page per site) <br /> Page _ of <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT [13.RENEWAL PERMIT 05.CHANGE OF INFORMATION(Specify change- E17.PERMANENTLY CLOSED SITE <br /> (Check one item only) �1 ❑4.AMENDED PERMIT meal use only) ❑8.TANK REMOVED 400 <br /> 06.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 <br /> Circle K Stores Inc. #2705449/02479/05449 f A D D U �{ C <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT' <br /> PACIFIC AVE/ RIVARA RD ® 1. CORPORATION ❑ 5. COUNTY AGENCY' <br /> ❑2. INDIVIDUAL ❑ 6. STATE AGENCY' <br /> BUSINESS TYPE ®1 GAS STATION ❑ 3.FARM ❑5.COMMERCIAL ❑ 3. PARTNERSHIP ❑ 7, FEDERAL AGENCY' 402 <br /> ❑2.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER <br /> 403 <br /> TOTAL NUMBER OF TANKS Is faGlily on Indian Reservation or 9f owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE Irustlande4 division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 3 404 ❑Yes ®N0405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> FIROPERTY OWNER NAME 407 PHONE 408 <br /> Circle K Stores Inc. (714)428-6572 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. Box 52085 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Phoenix AZ 85072 <br /> PROPERTY OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 413 <br /> ❑ 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERALAGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Circle K Stores Inc. <br /> MAILING OR STREET ADDRESS 416 <br /> P.O. Box 52085 <br /> CITY STATE 416 ZIP CODE 419 <br /> 417 <br /> Phoenix AZ 85072 <br /> TANK OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 420 <br /> ® 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERALAGENCY <br /> TY(TK)HQ I 4 0 3 2 O 7 3 Call(916)322-9669 if questions arise 421 <br /> 4 <br /> INDICATE METHODS) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND 7. STATE FUND ❑ 10. LOCAL GOV=T MECHANISM <br /> ® 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ B. STATE FUND&CFO LETTER ❑99. OTHER: <br /> ❑ 3. INSURANCE ❑ 6. F EMPTION ❑ 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal notifications and roiling. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK OW NER 423 <br /> Legal notifications <br /> and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> 1111 A"' I ANT SIGNATI IRE <br /> Card tion. I certify that the information provided herein is true and accurate to the best of my knov4edge. <br /> SIG ATURE tFAPP ICANT DATE424 PHONE 425 <br /> 13 add. (925)277-2404 <br /> NAME OF PLf7P ht LICANT(print) IF TITLE OF APPLICANT 426 <br /> Janette M. Thompson For Circle K Stores, Inc. Regional Compliance Specialist <br /> STATE UST FACILITY NUMBER(For local use only) 427 1998 UPGRADE CERTIFICATE NUMBER(For focal use only) 428 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />