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lei Il <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK �fL <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION �f <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> �� ;�. 1+'ACII:ITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY ID# 1 <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same ss FACndTY NAME or DBA-Doing Business As) 3. <br /> QUIK STOP MARKET#138 <br /> BUSINESS SITE ADDRESS 103• CITY 104• <br /> 1153 LINCOLN BLVD. TRACY <br /> FACILITY TYPE girl.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Ind' Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR [36.OTHER Trust lands? ❑Yes 0o <br /> o ° II. PROPERTYOWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 403. <br /> TRAINA, ET AL. c/o ALBERT REALTY 209 836-9492 <br /> MAILING ADDRESS 409. <br /> 503 WEST LARCH ROAD, SUITE D <br /> CITYSTATE 411. ZIP CODE 412• <br /> TRACY 7CA <br /> 95376 <br /> III. TANKOPERATOR INFORMATION <br /> TANK OPERATOR NAME 428.1. PHONE 428-2 <br /> QUIK STOP MARKETS, INC. (510)657-8500 <br /> MAILING ADDRESS 428.3 <br /> 4567 ENTERPRISE STREET <br /> CITY 423-4 1 STATE 423-5 ZIP CODE 423-6 <br /> FREMONT CA 94538 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> QUIK STOP MARKETS, INC. (510)657-8500 <br /> MAILING ADDRESS 416. <br /> 4567 ENTERPRISE STREET <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> FREMONT CA 94538 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT [I S.COUNTY AGENCY ❑ 6.STATE AGENCY 420• <br /> ❑ 7.FEDERAL AGENCY 018.NON-GOVERNMENT <br /> „_< • w ,' . <br /> V r BOARD.OF EQUALIZATION. UST STORAGE FEEsACCOUNT NUMBER ; ;" <br /> TY(TK)HQ 44- 1 0 1 8 7 6 3 Call the State Board of Equalization,Fuel Tax Division,if them are questions. 421. <br /> ,rpasx V �- :+«^x;:„r„xc« .� ,�."[ a>v' ,,o°` d •, -.. "tx i a�w; � l ,� <br /> PERMIT�HOLDER INFORMATION <br /> re e <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> e3.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 accurate and in full compliance with legal requirements. <br /> APPLIC IGNAT DATE 424. PHONE 425• <br /> SEPT. 23, 2010 510 445-2285 <br /> APPLICANT NAME(print) 426• APPLICANT TITLE 427 <br /> MIKE KARVELOT, for Quik Stop Markets,Inc. DIRECTOR, ENVIRONMENTAL AFFAIRS <br /> UPCF UST-A Rev.(12/2007) <br />