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UMIFIED PROGRAM CONSOLIDATED FO <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION X 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 PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 404. <br />FACILITY ID # <br />i� <br />3 <br />(Agency Use Only <br />_ <br />1 <br />1 <br />ELE=) <br />-.1 1 <br />BUSINESS NAME (same as FACILITY NAME. or DBA - Doing Business As) 3 <br />Quik Stop #144 <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />7272 West Lane <br />Stockton <br />FACILITY TYPE x 1. MOTOR VEHICLE FUELING ao3. <br />❑ 2. FUEL DISTRIBUTION <br />aos. <br />Is the facility located on Indian Reservation or <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />Trust lands? ❑ Yes x No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />PHONE 408. <br />Quik Stop Markets, Inc. <br />1 510-657-8500 <br />MAILING ADDRESS 409. <br />4567 Enterprise Street <br />CITY 410. <br />STATE 411. <br />ZIP CODE atz. <br />Fremont <br />CA <br />94538 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1. <br />PHONE 428-2 <br />Quik Stop Markets, Inc. <br />510-657-8500 <br />MAILING ADDRESS 428-3 <br />4567 Enterprise Street <br />CITYazaa <br />STATE 428-5 <br />ZIP CODE 429-6 <br />Fremont <br />CA <br />94538 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME ala. <br />PHONE 415. <br />Quik Stop Markets, Inc. <br />510-657-8500 <br />MAILING ADDRESS 416. <br />4567 Enterprise Street <br />CITY 417. <br />Fremont <br />STATE 418. <br />CA <br />ZIP CODE 419. <br />94538 <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. <br />❑ 7. FEDERAL AGENCY X 8. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 1 1 Call the State Board of Equalization, Fuel Tax Division, if there are questions. 42I. <br />VI. PERMIT HOLDER INFORMATION <br />Issue permit and send legal notifications and mailings to: ❑ 1. FACILITY OWNER ❑ 4. TANK OPERATOR 423 <br />X 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) 406. <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the information provided herein is true, <br />accurate, and in full compliance with le al requirements. <br />APPLICANT -SIG ATURE <br />DATE 424. PHONE 425. <br />-c, (916) 373-1166 <br />APPLICANT N (print) 426. <br />APPLICANT TITLE 427 <br />Dulcinea Webb <br />Compliance Manager <br />UPCF UST -A Rev. (12/2007) <br />