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Amok <br /> 01011 n0^f1__C2AAA 1+f%k10f%I 111ATCIl 0^ <br /> UNDERGROUND STORAGE TANKS - FACILIT O 017.101 <br /> (one page per site) Page/of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT 3.RENEWAL PERMIT [I5.CHANGE OF INFORMATION [37.PERMANENTLY CLOSED SITE <br /> (Check one item only) 4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I ILIT' 1 SIT I �� <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 AQILJT - a'`., I I <br /> 1 <br /> Quik Stop Market#121 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> Union Road ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ®1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY- 402 <br /> 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 <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 2 404 ❑ Yes ID No 405 406 <br /> II RF"t"1t �11+ JIiIAT1 <br /> PROPERTY OWNER NAME 407 PHONE 409 <br /> George & Nancy Yamashita 408-258-4372 <br /> MAILING OR STREET ADDRESS 409 <br /> 3465 Canyon Creek Drive <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> San Jose CA 95132 <br /> PROPERTY OWNER TYPE ❑1.CORPORATION ®2. INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> [:13.PARTNERSHIP ❑5.COUNTY AGENCY ❑7. FEDERAL 413 <br /> �I YANawI�ER INFQRMAT11ok <br /> . � <br /> A <br /> TANK OWNER NAME 414 PHONE 415 <br /> Quik Stop Markets, Inc. 510-657-8500 <br /> MAILING OR STREET ADDRESS 416 <br /> 4567 Enterprise Street <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Fremont CA 94538 <br /> TANK OWNER TYPE ® 1.CORPORATION [:12. INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [16.STATE AGENCY ago <br /> t, ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> N. = � ERE 11,P�UN7421'', � <br /> INS <br /> , <br /> TY(TK) HQ 44-01 1 18 1 7 1 6 13 1 Call (916)322-9669 if questions arise 421 <br /> Y� 0�I ► R PSI ;S IIT <br /> INDICATE [:11.SELF-INSURED <br /> ❑4.SURETY BOND ®7.STATE FUND [:110.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER:_ <br /> (D 3.INSURANCE [16.EXEMPTION [19.STATE FUND&CD 422 <br /> I# I.I»GA1« hNTIFICATIC)�1dAND.`MAILING`ADDRESS <br /> I <br /> Check one box to indicate which address should be used for legal notifications and mailing. 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK <br /> OWNER <br /> h AF F'LI AN 1G�IATURE i <br /> N <br /> .�o x <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF PLIC DATE azaPHONE azs <br /> -d 510-445-2285 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Mike Karvelot, for Quik Stop Markets, Inc. Director of Environmental Affairs <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />