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} <br /> ! SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK 7111QC <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> E: <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400_ <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMrr <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY 0# _ 1 <br /> 3 mgwo'Use Only) <br /> BUSINESS NAME(Son»FAMM NAM or DBA-Dons Hew As) 3. <br /> QUIK STOP MARKET#132 <br /> BUSINESS SITE ADDRESS 103• CITY too. <br /> 3555 HAMMER LANE STOCKTON <br /> FACILITY TYPE Kj.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 40. Is the facility located on Indi V4MVation or 403. <br /> [33.FARM ❑ 4.PROCESSOR ❑ 6-OTHER. Trust lands? ❑Yes ( lo <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 40• <br /> ADACHI INVESTMENT, LLC 41 396-6961 409. <br /> MAILING ADDRESS <br /> 1991 SUN MOR AVENUE <br /> CITY 410. 1 STATE 411. ZIP CODE 411 <br /> MOUNTAIN VIEW CA 94040 <br /> M. TANK OPERATOR INFORMATION <br /> TANKOPERATORNAME 423'1• PHONE 423-2 <br /> QUIK STOP MARKETS, INC. (510)657-8500 <br /> MAILING ADDRESS 42s 3 <br /> 4567 ENTERPRISE STREET <br /> CITY 42" 1 STATE 423-3 ZIP CODE 4 <br /> FREMONT CA 94538 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> QUIK STOP MARKETS INC. (510)657-8500 <br /> MAMG ADDRESS 416 <br /> 4567 ENTERPRISE STREET <br /> CITY 417. STATE 418• 1 22 CODE 419. <br /> FREMONT ICA 94538 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑�/5.COUNTY AGENCY [16.STATE AGENCY 420• <br /> ❑ 7.FEDERAL AGENCY 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 0 1 8 7 6 3 Call the State Board of Egwiization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permt and said legal notifications and nail np to: ❑,,,,�1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> I!I 3.TANK OWNER ❑ 5.FACl1=OPERATOR_ <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> Cz <br /> girmc ?ION: I certw Hutt the Inbrmation prwidetl herein b tin &=Mt and In fall compgowwk>tmg regwremmt5.\',.--'- <br /> APPLJCANTSX3KATUREni P>SIB, azs. <br /> JUNE 3, 2009 510 445-2285 h <br /> APPLICANT NAME(print) 423. APPLICANT TITLE <br /> MIKE KARVELOT, for Quik Stop Markets,Inc. DIRECTOR, ENVIRONMENTAL AFFAIRS <br /> UPCF UST A Rev.(12nM <br />