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PIED PROGRAM CONSOLIDATED FOqj `oI I�,� <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY PIP11 I n3 <br /> (one page per site) Page of <br /> TYPE OF ACTION ❑ I.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/ SITE INFORMATION <br /> BUSINESS OQ�I <br /> C E(Same as FACILITY NAME orDBA-Doing BusinDnesss�As) 3 FACILITY IDI <br /> k #2708671 Scab /j lykP tom. <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT* <br /> Davis ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which <br /> REMAINING AT SITE trustlands? operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes N No 405 1 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Circle K Stores Inc. <br /> MAILING OR STREET ADDRESS 409 <br /> PO Box 52085 <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> Phoenix AZ 85072 <br /> PROPERTY OWNER TYPE ® L CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Conoco Phillips Company 510-245-5176 <br /> MAILING OR STREET ADDRESS 416 <br /> 76 Broadway <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Sacramento CA 95818 <br /> TANK OWNER TYPE ® I.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 4 1 1 19 19 1 8 1 Call(916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) Z 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: ----- <br /> ❑3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ I.FACILITY ❑2. PROPERTY OWNER ®3.TANK OWNER 423 <br /> VII. APPLICANT SIGNATURE <br /> Certification-1 certify that the informal n provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICAN DATE 424 PHONE 425 <br /> 5/30/03 (916)635-2444 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Becky Weaver Agent for Owner <br /> �77 ST FACILITY NUMBER(For local useonly) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) 171 Formerly SWRCB Form A <br />