COMPLIANCE INFO_1986-2005 - Laserfiche WebLink

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IED PROGRAM CONSOLIDATED FORNIQ PRS:PR0231413 FAC#:FA0003122 UNDERGROUND STORAGE TANKS -FACILITY l�� (one page per ite) ( o TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANE TLY CLOSED SITE (Check one item only) ❑4.AMENDED PERMIT ❑ 8.TANK REMOVED ❑6.TEMPORARY SITE CLOSURE 400 I.FACILITY/SITE INFORMATION 1153 LINCOLN BLVD,TRACY BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) ; FACILITY ID# PR IDN UIK STOP MARKETS 138 q FA0003122 PR0231413 1 NEAREST CROSS STREET f FACILITY OWNER TYPE r'h }�y, r 401 ,/ ❑4.LOCAL AGENCY/DISTRICT' .� 1 �52),x�`F,}' L� 1.CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS 1.GAS STATION ❑ 3.FARM ❑ 5.COMMERCIAL ❑ 2.INDIVIDUAL TYPE ❑ ❑ 6.STATE AGENCY* 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY* 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) n 404 El Yes ®No aos QUIK STOP MARKETS INC aob II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 4011 PHONE 409 C 209 �§,--� MAILING OR STREET ADDRESS ao9 I'd'+6�$6X rJ�$5 L W. .c9 t2 C Rd ti-I' CITY 41U STATE 411 ZIP CODE 412 CA -94*3--�- 9,5 76 PROPERTY OWNER TYPE [, 1.CORPORATION El 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY E3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONEJ/G S'7- 1 L�O 415 UIK STOP MARKETS INC MAILING OR STREET ADDRESS 416 7 CITY 417 STATE 418 1 ZIP CODE 419 FREMONT CA 94537 TANK OWNER TYPE ❑X 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT 1:16.STATE AGENCY 420 ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY W.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 44-018763 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIIAL RESPONSIBILITY INDICATE METHOD(s) El1.SELF-INSURED El4.SURETY BOND 9? 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER 19199.OTHER 92r'3.INSURANCE 1:16.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS �T/� Check one box to indicate which address should be used for legal notifications and mailing. 1.FACILITY ❑2.PROPERTY OWNER LS3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. SIGNATURE OF APAICANJ DATE 424 PHONE 425 ,5"-,70 6),.3 y, ZY\5,� NAME OF APPLICANT(print) lf 426 TITLE OF APPLICANT 427 /C t,- ��'��'t,'�0 t �� (�.S'.rel. .r.✓c;. l{�,i2�c ft.�.� �--� ,(;i��,�tit�>7�-��.�->( /��- STATE UST FACILITY NUMBER(For local ve only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)