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U , IED PROGRAM CONSOLIDATED F .M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ f <br /> TYPE OF ACTION ❑1.NEW SITE PERMIT [:13.RENEWAL PERMIT ®5.CHANGE OF INFORMATION(Specify change- [:]7.PERMANENTLY CLOSED SITE <br /> (Check one dem only) ❑4.AMENDED PERMIT local use only) 08.TANK REMOVED 400 <br /> ❑6.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 <br /> BUSINESS SITE ADDRESS 401 FACILITY OWNER TYPE ❑ 4. LOCAL AGENCY/DISTRICT' <br /> 7647 PACIFIC AVE ® 1. CORPORATION ❑ 5. COUNTYAGENCY- <br /> ❑2. INDIVIDUAL ❑ 6. STATE AGENCY' <br /> BUSINESS TYPE ®1.GAS STATION ❑ 3.FARM ❑5.COMMERCIAL ❑ 3. PARTNERSHIP <br /> [:12.DISTRIBUTOR ❑ 4.PROCESSOR [:16.OTHER ❑ 7 FEDERAL AGENCY- 402 <br /> 403 <br /> TOTAL NUMBER OF TANKSIs facility on Indian Reservation or 'If owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE trustlands? division,section or office which operates the UST. <br /> (This is the contact person for the tank records.) <br /> 3 404 ❑Yes ®No 405 406 <br /> II.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 ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Circle K Stores Inc. 1 (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 ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 420 <br /> ® 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> JV RQARD OF FIX 1AI-17AIlON I ISI STORAGE FEE ACC-01 INT NI Imiclu;R <br /> TY(TK)HQ 4 4 0 3 2 0 7 3 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) ❑ 1. SELF-INSURED ❑ 4. SURETY BOND 7. STATE FUND [:110. LOCAL GOV=T MECHANISM <br /> ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND&CFO LETTER ❑99. OTHER: <br /> [K 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND&CD 422 <br /> Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1. FACILITY -] 2. PROPERTY OWNER ® 3. TANK OWNER 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification: I certify that the inforrnaaon provided herein is We and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLI ANT DATE 424 PHONE 425 <br /> `-t o 1 (909) 270-5193 <br /> NAME OF APPLICANT nnt) TITLE O APPLIC NT 426 <br /> Michelle Wilson West Coast Environmental Compliance Manager <br /> STATE UST FACILITY NUMBER(For local use only) 427 1998 UPGRADE CERTIFICATE NUMBER(Forloca/use only) 428 <br /> UPCF(1/99 revised) 5 Formerly SWRCB Form A <br />