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Aug 13 03 12:04p Ri and Thompson 925-226-2050 <br />i UNIFIED PROGRAM CONSOLIDATED FORM <br />TANKS <br />UNDERGROUND STORAGE TANKS -- FACILITY <br />TYPE OF ACTION ❑t. NEW SITE PERMIT ❑3. RENEWAL PERMIT" 195. CHANGE of INFORMATION (Specify change - <br />(Check one item only) 04. AMENDED PERMIT local use oMy) <br />05. TEMPORARY SITE CLOSURE <br />p.5 <br />�F-0- <br />(one page per site) 1i <br />Page ___. of <br />❑7. PERMANENTLY CLOSED SITE <br />❑8- TANK REMOVED 400 <br />STATE UST FACILITY NUMBER (Forlocal use <br />427 1 1998 UPGRADE CERTIFICATE NUMBER (For)ocaN use only) 428 <br />1. FACILITY / SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 <br />FACILITY ID # <br />1 <br />#2705448 <br />0" 4, '/3 8 <br />BUSINESS SITE ADDRESS 401 <br />FACILITY OWNERTYPE <br />® 1. CORPORATION <br />4. LOCAL AGENCYIDISTRICT` <br />1403 COUNTRY CLUB BLVD <br />❑2. INDIVIDUAL <br />❑ 3. PARTNERSHIP <br />❑ S. COUNTYAGENCY' <br />❑ 6. STATEAGENCY' <br />❑ 7. FEDERAL AGENCY- 402 <br />BUSINESS TYPE ® 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL <br />[:12. DISTRIBUTOR ❑ 4, PROCESSOR ❑ 6. OTHER <br />403 <br />TOTAL NUMBER OF TANKS <br />Is fatality on Indian Reservation or `r owner of UST is a public agency: name of supervisor of <br />REMAINING AT SITE <br />trustlandsl <br />division, section or office which operates the UST. <br />(This the contact person for the tank records.) <br />4 404 <br />C] Yes N No405 406 <br />11. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 406 <br />Circle K Stores Inc. <br />1(714) <br />428-6572 <br />MAILING OR STREET ADDRESS 409 <br />P.O. Box 52085 <br />CITY 410 <br />STATE 411 <br />ZIP CODE 412 <br />Phoenix <br />AZ 185072 <br />PROPERTY OWNER TYPE <br />❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY I DISTRICT <br />❑ 6. STATE AGENCY 413 <br />❑ 1. CORPORATION <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENGY <br />❑ 7. FEDERAL AGENCY <br />Ill. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE 415 <br />Circle K Stores Inc. <br />MAILING OR STREET ADDRESS 416 <br />P.O. Box 52085 <br />CITY 417 <br />STATE 418 <br />ZIP CODE 419 <br />Phoenix <br />AZ <br />85072 <br />TANK OWNER TYPE <br />❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/ DISTRICT <br />❑ 6. STATEAGENCY 420 <br />® 1. CORPORATION <br />❑ 3. PARTNERSHIP ❑ 5. COUNTYAGENCY <br />❑ 7. FEDERALAGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ <br />4 <br />4 <br />1 -_1_012101713131 <br />Call (916) 322-9669 if questions arise <br />421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHODS) ❑ 1. SELF-INSURED <br />❑ 4. SURETY BOND ❑ 7. STATE FUND <br />❑ 10. LOCAL GOV=T MECHANISM <br />❑ 2. GUARANTEE <br />❑ 5. LETTER OF CREDIT❑ B. STATE FUND & CFO LETTER <br />❑ 99. OTHER: <br />N 3. INSURANCE <br />El 6. EXEMPTION ❑ 9. STATE FUND & CD <br />422 <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and mailing. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK OWNER 423 <br />Legal notifications and mailings wilt be sent to the tank ownerunless box 1 or2 is checked. <br />VII. APPLICANT SIGNATURE <br />Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGN F APPL NT <br />DATE <br />424 <br />PHONE 425 <br />(510) 245-5218 <br />NAME 0 �PPLICAN ' pn <br />TITLE OF APPLICANT 426 <br />Janette Thompson For Circle K Stores, Inc. <br />Regional Compliance Specialist <br />STATE UST FACILITY NUMBER (Forlocal use <br />427 1 1998 UPGRADE CERTIFICATE NUMBER (For)ocaN use only) 428 <br />