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IIUN' 4D STATES BANKRUPTCY COURT, DIS' 7CT OF ARIZONA In re: Case Nos. 90-05052-PHX-GBN to 90-05075-PHX-GBN THE CIRCLE \\\OR;AATT/TION, ET AL., (Jointly Administered) DEBTORS. PROOF OF CLAIM SEE INSTRUCTIONS AT BOTTOM OF REVERSE SIDE CREDITOR NO: 17245 This claim is asserted against: SAN JOAQUIN HEALTH DISTRICT / PO Box 2009/1601 E Hazelton A (Xl The Circle K Corporation 90-05052-PHX-GBN Stockton CA 95201 ( ) CIRCLE K CONVENIENCE STORES, INC. 90-05053-PHX-GBN ( ) Circle K Management Company 90-05054-PHX-GBN ( ) LAR-LIN, INC. 90-05055-PHX-GBN 1 ) FIRST CIRCLE PROPERTIES, INC. 90-05056-PHX-GBN If no label in box above or if label ( ] UtoteM, Inc. 90-05057-PHX-GBN information is incorrect, please complete: ( ) UtoteM MARKETS OF ARIZONA, INC. 90-05058-PHX-GBN San Joaquin County Public Healtl U Totem of Alabama, Inc. 90-05059-PHX-GBN 2^F-V3,B66 — Health piV, U-TOTEM OF COLORADO INC. 90-05060-PHX-GBN Name of Creditor ( ) U-TOTEM OF MIAMI, INC. 90-05061-PHX-GBN ( l TIF TOC SYSTEMS, INC. 90-05062-PHX-GBN 445 N. San Joaquin St. ( ) MONTERRE PROPERTIES, INC. 90-05063-PHX-GBN Street Address ( ) SHOP 8 GO, INC. 90-05064-PHX-GBN f ) CIRCLE K GENERAL, INC. 90-05065-PHX-GBN Stockton, Ca. 95202 ( ) CIRCLE K HAWAII, INC. 90-05066-PHX-GBN City/State/Zip Code l ) COMBINED AVIATION CO. 90-05067-PHX-GBN f )00 Charter Marketing Company 90-05068-PHX-GBN Amount of claim: $ 1 ) Charter Marketing Company (Connecticut) 90-05069-PHX-GBN 1 ) MR. B'S OIL CO., INC. 90-05070-PHX-GBN Type of Claim: ()0 General Unsecured ( ) MR. B'S FOOD MART, INC. 90-05071-PHX-GBN ( ) Secured (See paragraph 8) ( ) NPI Corporation 90-05072-PHX-GBN ( ) Priority (See paragraph 9) ( ) OLD COLONY PETROLEUM 90-05073-PHX-GBN COMPANY, INC. Basis for claim: [ ) Goods purchased ( ) Now England Petroleum Distributors, Inc. 90-05074-PHX-GBN l ) Services performed ( ) 44th Street B Canelback Limited Partnership 90-05075-PHX-GBN ( ] Monies loaned ( ) Contractual obligation f ) Personal injury/Wrongful This prpof of claim: death/Property damage l ) Employment matter ( ) is the first filed proof of claim evidencing the asserted claim 00 Other:Annua T ,S T ( ) amends/supplements a proof of claim filed on permit fee. ( ) replaces/supersedes a proof of claim filed on I 1. The debtor was, at the time of the filing of the petition initiating this case (May 15, 1990), and still is, indebted or liable to this claimant in the sum of s 5 0 0 . 0 0 2. The consideration for this debt or the ground of liability is as follows: Annual Under round torage— Tank Permit Fee. Site location: 16470 Cambridge Lathrop Ca ifornia (Circle ircl K) Computer # CIRCLI6 1205 3. If the claim is founded upon a writing, the writing on which this claim is founded (or a duplicate thereof) is (X) attached hereto, or l ) cannot be attached hereto for the following reason: (SEE REVERSE SIDE) CLAIM NO.