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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT A /za), <br /> UNDERGROUND STORAGE TANK n D 70 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION �" I I <br /> (One form per facility) <br /> TYPE OF ACTION 1.NEW PFRAN FOAPY ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400' <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# 1 -7 <br /> 2 (4geney Use only) F A - 0 0 0 - 1 0 6 0 <br /> BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) 3. <br /> QUIK STOP MARKET#76 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1030 SOUTH OLIVE AVENUE STOCKTON <br /> FACILITY TYPE [r1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on InReservation or 405' <br /> [13.FARM ❑ 4.PROCESSOR C16.OTHER Trust lands? C] diar; <br /> Yes o <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408. <br /> WILLIAM SCHARFEN (650)941-4108 <br /> MAILING ADDRESS 409. <br /> 26792 PALO HILLS DRIVE <br /> CITY 4t0 STATE 411. ZIP CODE 412• <br /> LOS ALTOS HILLS CA 94022 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 428-2 <br /> QUIK STOP MARKETS, INC. (510) 657-8500 <br /> MAILING ADDRESS 428-3 <br /> 4567 ENTERPRISE STREET <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> FREMONT CA 94538 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415. <br /> QUIK STOP MARKETS, INC. (510) 657-8500 <br /> MAILING ADDRESS 416. <br /> 4567 ENTERPRISE STREET <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> FREMONT CA 94538 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT C1 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY W S.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 Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ II.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> W 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. 1 PHONE 425. <br /> AUG. 26, 2009 510 445-2285 <br /> APPLICANT NAME(print) 426 APPLICANT TITLE 427 <br /> MIKE KARVELOT, for Quik Stop Markets,Inc. DIRECTOR, ENVIRONMENTAL AFFAIRS 0 . <br /> UPCF UST-A Rev.(12/2007) <br /> `t.'iy. U bwagJ�� <br /> f <br />