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' <br /> ` <br /> UNDERGROUND STORAGE TANKS - (one page per site) Page / of <br /> TYPE OF ACTION 1.NEW SITE PERMIT El 3.RENEWAL PERMIT [I 5.CHANGE OF INFORMATION [I TPERMANENTLY CLOSED SITE <br /> (Check one item only) 4.AMENDED PERMIT specify change local use onl 8.TANK REMOVED <br /> F [3&TEMPORARY SITE CLOSURE 400 <br /> BUSINESS NAME Isame as FACILITY NAME or DBA-Doing Business As) 3 <br /> Quik Stop Market#124 t). Ll <br /> NEAREST CROSS STREET 401 FACII ITY OWNER TYPE 4.LOCAL GENCY/DISTRICT* <br /> East Alameda Street 0 1.CORPORATION E]5.COUNTY AGENCY* <br /> BUSINESS 1.GAS STATION [13.FARM 0 5. COMMERCIAL [] 2. INDIVIDUAL E]6.STATE AGENCY* <br /> TYPE 2.DISTRIBUTOR [14.PROCESSOR[16. OTHER 403 El 3. PARTNERSHIP [17.FEDERAL AGENCY- 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of LIST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the LIST(This is the contact person for the tank records.) <br /> 3 404 El Yes ED No 405 406 <br /> 111 -4 <br /> jz <br /> George and Nancy Yamashita 408-258-4372 <br /> MAILING OR STREET ADDRESS 409 <br /> 3465 Canyon Creek Drive <br /> CITY 410 STATE ZIP CODE 412 <br /> San Jose CA 95132 <br /> PROPERTY OWNER TYPE 1.CORPORATION [D 2.INDIVIDUAL El 4.LOCAL AGENCY/DISTRICT E]6-STATE AGENCY <br /> [:13.PARTNERSHIP El 5.COUNTY AGENCY 7. FEDERAL 413 <br /> I AW IN _21 2K NEW <br /> MEQ <br /> TANK OWNER NAME 414 PHONE 415 <br /> Quik Stop Markets, Inc. 510-657-8500 <br /> MAILING OR STREET ADDRESS 416 <br /> 4567 Enterprise Street <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Fremont CA 94538 <br /> TANK OWNER TYPE 1.CORPORATION 2. INDIVIDUAL [:14.LOCAL AGENCY/DISTRICT E]6.STATE AGENCY 420 <br /> E13.PARTNERSHIP []5.COUNTY AGENCY [17. FEDERAL AGENCY <br /> 't ApOpOT, <br /> INDICATE 1.SELF-INSURED 4.SURETY BOND El 7.STATE FUND [110.LOCAL GOVT MECHANISM <br /> METHOD(s) [12.GUARANTEE 0 5. LETTER OF CREDIT 8.STATE FUND&CFO LETTER 99.OTHER: <br /> 0 3. INSURANCE El 6.EXEMPTION 9.STATE FUND&CD 422 <br /> LIE iN ,AD RES <br /> Check one box to indicate which address should be used for legal notifications and mailing. 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. [1 1.FACILITY E:12. PROPERTY OWNER 3.TANK <br /> OWNER <br /> PL C R7 <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE PIF APPL�qANT DATE 424 PHONE 425 <br /> 510-445-2285 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Mike Karvelot, for Quik Stop Markets, Inc. Director of Environmental Affairs <br /> STATE LIST FACILITY NUMBER(For local use only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429_ <br /> UPCF (1/QQrevised) Formerly GVVRCBForm A <br />