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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATIONE: <br /> C" <br /> (One form per facility) <br /> TYPE OF ACTION 1.NEW PEi8MH FORM C15.CHANGE OF INFORMATION El7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L;FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# I. <br /> IFIAII-] 0101 <br /> 2 (Agency Use Only) 0 1 6 5 9 <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3' <br /> QUIK STOP MARKET#39 <br /> BUSINESS SITE ADDRESS 103. CITY 1oa. <br /> 2285 EAST FREMONT STREET STOCKTON <br /> FACILITY TYPE Pl.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ENo <br /> IL PROPERTY`OWNERWORMATION <br /> , �. _ . <br /> PROPERTY OWNER NAME aoz ,PHONE 408. <br /> DILLON REAL ESTATE CO., INC. "620)694-5550 <br /> MAILING ADDRESS 409 <br /> 800 EAST FOURTH AVENUE <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> HUTCHINSON KS 67504-1266 <br /> uwe <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429-1. PHONE 428-2 <br /> QUIK STOP MARKETS, INC. (510) 657-8500 <br /> MAILING ADDRESS a29 a <br /> 4567 ENTERPRISE STREET <br /> CITY 429-4 STATE aza.s ZIP CODE 429 6 <br /> FREMONT ICA 94538 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> QUIK STOP MARKETS, INC. (510)657-8500 <br /> 416. <br /> MAILING ADDRESS <br /> 4567 ENTERPRISE STREET <br /> CITY 417. 1 STATE 419. ZIP CODE 419. <br /> FREMONT CA 94538 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY e8.NON-GOVERNMENT <br /> Y. BOARI3OF E,,-UATION UST STORAGE EEE 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.PERIVIIT HOLDER INFORMATION , <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ,❑,/1.FACILITY OWNER [14.TANK OPERATOR <br /> I!7 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Pubic Agencies Only) 'i`... <br /> VII.APPLICAIVT?SIGNAT$VRE <br /> CERTIFICATION: I certify that the i formation provided herein is true accurate,and in full compfiance with legal re uirements. <br /> APPLICANT SIGNATUREDATE azo. PHONE 42s. <br /> AUG. 28, 2009 510 445-2285 <br /> 426• APPLICANT TITLE 427 <br /> APPLICANT NAME(print) ;b <br /> MIKE KARVELOT, for Quik Stop Markets, Inc. DIRECTOR, ENVIRONMENTAL AFFAIRS <br /> UPCF UST-A Rev.(12/2007) <br />