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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK• <br /> E: <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One fo—per faciNty) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION [17.PERMANENT FACIL TY CLOSURE <br /> (Chock 0ne imm only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACH=INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY ID* 1' <br /> 3 (AS-W Use 0*) — — <br /> BUSINESS NAME(Soca n FACH.HY NAME or DHA-Doing amines As) 3. <br /> QUIK STOP MARKET#124 <br /> BUSINESS SITE ADDRESS 103• CITY too. <br /> 505 NORTH MAIN STREET MANTECA <br /> FACILITY TYPE grl.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION ' Is the facility located an hldiryReservatim or 403' <br /> 3.FARM 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 447• PHONE 40, <br /> GEORGE S NANCY YAMASHITA 408 258-4372 <br /> MAILING ADDRESS 40, <br /> 3465 CANYON CREEK DRIVE <br /> CITY 410 1 STATE 411. ZIP CODE 412. <br /> SAN JOSE CA 95132 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 424 i. PHONE 42L2 <br /> QUIK STOP MARKETS INC. (510)657.8500 <br /> MAILING ADDRESS 424-3 <br /> 4567 ENTERPRISE STREET <br /> CITY 424 STATE 4243 I ZIP CODE a" <br /> FREMONT CA 94538 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 413. <br /> QUIK STOP MARKETS INC. (510)657-8300 <br /> MAILING ADDRESS 416 <br /> .,067 ENTERPRISE STREET <br /> CITY 417. STATE 414. ZIP CODE 419. <br /> FREMONT I CA 194538 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT 13 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ip &NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(Tic)HQ 44- 1011181716131 Call the State Board of Egom isMiott.Foal Tait Divisim if there m Questions. 421, <br /> VL PERMIT HOLDER INFORMATION <br /> Issue permit and send leSal nobficaims and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> N(3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Asalcies Only) <br /> VII.APPLICANT SIGNATURE " <br /> CERTIFICATION: I caft Hat tie wmrk"pnwmw6ee4ir:it III mini imifMf w1H <br /> APPLICANT SIGNATURE DATE ax4 PHONE ( � <br /> APRIL 8,2010 510 445-2285 <br /> APPLICANT NAME(print) 42d• APPLICANT TITLE <br /> MIKE KARVELOT for Qulk Stop Markets,Inc. DIRECTOR, ENVIRONMENTAL AFFAIRS , <br /> UFCF UST-A Row.(12/287) .rets 1•. <br /> Ed' <br /> kf!'JA t <br />