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bmIFIED PROGRAM CONSOLIDATED FOh7ft <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION X 1.NEW PERMIT El 5.CHANGE OF INFORMATION [17.PERMANENT FACILITY CLOSURE 4W <br /> (Check one it..only) El3.RENEWAL PERMIT [16.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY a04' FACILITY ID# <br /> 2 1 (Agency Use Only) <br /> BUSINESS NAME(59me u FACILITY NAME m DBA—Doing Bu9inere A4) <br /> Circle K#2701205 <br /> BUSINESS SITE ADDRESS ID3. CITY log. <br /> 16470 Cambridge Drive Lathrop <br /> FACILITY TYPE x 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403, Is the facility located on Indian Reservation or 405- <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes x No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Circle K Stores, Inc. 209-858-4116 <br /> MAILING ADDRESS °09' <br /> 495 East Rincon Street, Ste 150 <br /> CITY 410. STATE 411. ZIP CODE 412, <br /> Corona CA 92879 <br /> TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429-1 PHONE 429-2 <br /> Circle K Stores, Inc. 805-523-2949 <br /> MAILING ADDRESS 429.3 <br /> 495 East Rincon Street, Ste 150 <br /> CITY J10 STATE 411, ZIP CODE 411 <br /> Corona CA 92879 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414_ PHONE 415. <br /> Circle K Stores, Inc. 805-523-2949 <br /> MAILING ADDRESS 419 <br /> 495 East Rincon Street, Ste 150 <br /> CITY 410 STATE 411. ZIP CODE 412. <br /> Corona CA 92879 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY X 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. J21 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue ennit and send legal notifications and mailings to: 423 <br /> p g g ❑ L FACILITY OWNER ❑ 4.TANK OPERATOR <br /> X 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APP- CANT SIGNATURE DATE 424 PHONE 425. <br /> `� 2- -1 -ll 916 373-1166 <br /> APPEMANT NAME(print) 426 APPLICANT TITLE 427 <br /> Dulcinea Covan Compliance Manager <br /> UPCF UST-A Rev.(122007) <br />