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IED PROGRAM CONSOLIDATED FOR UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - FACILITY INFORMATION (One form per facility) TYPE OF ACTION X 1. NEW PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 400. (Check one item only) ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID # 1 3 (Agency Use Only) _ BUSINESS NAME (Same as FACULTY NAME or DBA - Doing Business As) 3. Quik Stop #132 BUSINESS SITE ADDRESS 103. CITY 104. 3555 W. Hammer Lane Stockton FACILITY TYPE x 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or 405. ❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER Trust lands? ❑ Yes x No U. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. Quik Stop Markets, Inc. 510-657-8500 MAILING ADDRESS 409. 4567 Enterprise Street CITY 410. STATE 411. ZIP CODE 412. Fremont CA 94538 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1, PHONE 428-2 Quik Stop Markets, Inc. 510-657-8500 MAILING ADDRESS 428-3 4567 Enterprise Street CITY 428-4 STATE 428-5 ZIP CODE 428-6 Fremont CA 94538 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. Quik Stop Markets, Inc. 510-657-8500 MAILING ADDRESS 416. 4567 Enterprise Street CITY 417. STATE 418. ZIP CODE 419. Fremont 1 CA 94538 OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. ❑ 7. FEDERAL AGENCY X 8. NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY (TK) HQ 44- 1 r Call the State Board of Equalization, Fuel Tax Division, if there are questions. 421. VI. PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ❑ 1. FACILITY OWNER ❑ 4. TANK OPERATOR 423 X 3. TANK OWNER ❑ 5. FACILITY OPERATOR 406. SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) VII. APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true, accurate, and in full compliance with legal requirements. SIGNATURE DATE 424. PHONE 425. ® `1- 1 (916) 373-1166 APPLICANT NAME (print) 426. APPLICANT TITLE 427 Dulcinea Webb Compliance Officer UPCF UST -A Rev. (12/2007)