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UNOFD PROGRAM CONSOLIDATED F *4 <br /> TANKS !� <br /> UNDERGROUND STORAGE TANKS - FACILITY ✓U�' 1I44 <br /> (one pag si V <br /> -._ Page _ of \� <br /> TYPE OF ACTION ❑1,NEW SITE PERMIT [13.RENEWAL PERMIT 05.CHANGE OF INFORMATION(Spec/y change- ❑7.PERMANENTLY CLOSED SITE <br /> (Check one dem only) ❑4.AMENDED PERMIT local use only) ❑B.TANKREMOVED 400 <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I.FACILITY I SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 <br /> Circle K Stores Inc. #2705449 F/4 11033 <br /> BUSINESS SITE ADDRESS 401 FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT' <br /> 7647 PACIFIC AVE ® 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 fadlity on Indian Reservation or 'If owner of UST is a public agency:name of superdsor of <br /> REMAINING AT SITE lrustlends7 didsion,section or office which operates the UST. <br /> (This Is the contact person for the lank records.) <br /> 3 404 ❑Yes ®No 405 406 <br /> 11.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> BEST CALIFORNIA GAS LTD (510)245-5219 <br /> MAILING OR STREET ADDRESS 409 <br /> 13116 IMPERIAL HWY <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> SANTA FE SPRINGS CA 90670 <br /> PROPERTY OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 413 <br /> ❑ 1. CORPORATION 3. PARTNERSHIP ❑ S. COUNTYAGENCY ❑ 7. FEDERAL AGENCY <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Circle K Stores Inc. (909) 270-5193 <br /> MAILING OR STREET ADDRESS 416 <br /> 495 East Rincon Ste 150 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Corona CA 92879 <br /> TANK OWNER TYPE F-1 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 420 <br /> ® 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTYAGENCY ❑ 7. FEDERAL AGENCY <br /> TY(TK)HQ 4 1 4 1 1 0 3 2 1 0 7 3 Call(916)322-9669 if questions arise 421 <br /> Al RETROI EI IM I IST FINANC-1 STATE FUND <br /> INDICATE METHOD(S) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND 7. ❑ 10. LOCAL GOV=T MECHANISM <br /> ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ B. STATE FUND&CFO LEITER ❑99. OTHER: 422 <br /> ® 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND&CD <br /> Check one box to Indicate which address should be used for legal notifications and mailing. ❑ 1, FACILRY ❑ 2. PROPERTVOWNER ® 3. TANK OWNER 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is cracked. <br /> Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APP LI NT DATE 424 PHONE 425 <br /> 1 =ONE <br /> NAME OF APPLICANT knot TITLED APPUC NT 426 <br /> Michelle Wilson West Coast Environmental Compliance Manager <br /> STATE UST FACILITY NUMBER(For local use only) 427 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 428 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />