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FIED PROGRAM CONSOLIDATED ISM <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(one page per site) Page _ of <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT Z 5.CHANGE OF INFORMATION ❑ 'I.PERMANENTLY CLOSED SITE <br />(Check one item only) ❑ 4. AMENDED PERMIT specify change local use only ❑ 8. TANK REMOVED <br />❑ 63EMPORARY SITE CLOSURE 400 <br />I. FACILITY / SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3 <br />FACILITY ID# <br />_....:_ <br />Circle K # 2705446 <br />1 <br />NEAREST CROSS STREET 401 <br />FACILITY OWNER TYPE Lj 4. LOCAL GENCY/DISTRICT* <br />Pershing Ave <br />Z 1. CORPORATION p 5. COUNTY AGENCY* <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />BUSINESS Z 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 403 <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* 402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />*If owner of UST is a public agency: name of supervisor of division, section or office which <br />REMAINING AT SITE <br />trustlands? <br />operates the UST (This is the contact person for the tank records.) <br />3 404 <br />❑ Yes Z No 405 <br />1 406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 408 <br />Circle K Stores Inc. <br />MAILING OR STREET ADDRESS 409 <br />PO Box 52085 <br />CITY 410 <br />STATE 411 <br />ZIP CODE 412 <br />Phoenix 1 <br />AZ <br />85072 <br />PROPERTY OWNER TYPE Z 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 <br />PHONE 415 <br />Conoco Phillips Company <br />510-245-5176 <br />MAILING OR STREET ADDRESS 416 <br />76 Broadway <br />CITY 417 <br />STATE 418 <br />ZIP CODE 419 <br />Sacramento 1 <br />CA <br />95818 <br />TANK OWNER TYPE Z 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY 420 <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 1 4 1 1 1 9 1 9 18 1 Call (916) 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) Z 1. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 422 <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and mailing. <br />Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER Z 3. TANK OWNER 423 <br />VII. APPLICANT SIGNATURE <br />Certification - I certify that the information pro ided herein is true 2rd accurate to the best of my knowledge. <br />SIGNATURE OF APPLICANT <br />DATE 424PHONE <br />425 <br />5/30/03 <br />(916) 635-2444 <br />NAME OF APPLICANT (print) 426 <br />TITLE OF APPLICANT 427 <br />Becky Weaver <br />Agent for Owner <br />STATE UST FACILITY NUMBER (For local use only) 428 <br />1998 UPGRADE CERTIFICATE NUMBER (For local use only) <br />429 <br />UPCF (1/99 revised) 171 Formerly SWRCB Form A <br />