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AM <br /> .xFIED PROGRAM CONSOLIDATED FO _ <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION X 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# I <br /> 2 (Agency Use Only) <br /> BUSINESS NAME(Same.FACn,ITY NAME or DBA-Doing Business As) 3. <br /> Quik Stop #121 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1196 W. Louise Avenue Manteca <br /> FACILITY TYPE x 1.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 x No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Quik Stop Markets, Inc. 510-657-8500 <br /> MAILING ADDRESS 409. <br /> 4567 Enterprise Street <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Fremont CA 94538 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Quik Stop Markets, Inc. 510-657-8500 <br /> MAILING ADDRESS azs-3 <br /> 4567 Enterprise Street <br /> CITY 4284 STATE 428-5 ZIP CODE 428-6 <br /> Fremont I 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 a16. <br /> 4567 Enterprise Street <br /> CITY 417. STATE 418. 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 X 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> X 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com liance with legal re uirem ." <br /> AP T SIGNATURE DATE <br /> ata. PHONE azs. <br /> (916) 373-1166 <br /> APPLIeANT NAME(print) 426. APPLICANT TITLE 427 <br /> Dulcinea Covan Compliance Manager <br /> UPCF UST-A Rev.(12/2007) <br />