Laserfiche WebLink
n <br />I_1 <br />FIED PROGRAM CONSOLIDATED FOMF <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 r ryV �"I'tiri,4 �4 <br />�gl <br />>a'� t� <br />II II4 � �,�4 <br />I I: <br />rl I <br />TOTAL NUMBER OF USTs AT FACILIT3 404.FACILITY <br />CI LI <br />A Use Only) # <br />m a l <br />BUSINESS NAME (same as FACILITY NAME or DBA - Doing Business As) <br />3' <br />Quik Stop # 125 <br />BUSINESS SITE ADDRESS <br />103. <br />CITY 104. <br />1580 W. Main Street <br />Ripon <br />FACILITY TYPE x 1. MOTOR VEHICLE FUELING <br />❑ 2. FUEL DISTRIBUTION 403. <br />Is the facility located on Indian Reservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR <br />❑ 6. OTHER <br />Trust lands? ❑ Yes x No <br />mQ'Wu f 1 VIII( I.i r <br />"} 3 µ <br />(1414',, # III IY I I E f � I � u IY, �!I III ((IIIIIIII (IIIIIIII ` ,f 2f <br />VIII (IIIIIII NG 11 �'Nr ,'�, <br />"`;~➢ x��r"5 <br />� <br />114 <br />Ilk F a.'IYI, I. E II II 11+.�11II <br />r'• <br />II �! I III U1 Ix �I:11 (III I I X�1I117 n. t,+..:311�R�hh <br />PROPERTY OWNER NAME <br />x07. PI LONE 408. <br />Quik Stop Markets, Inc. <br />510-657-8500 <br />MAILING ADDRESS <br />409. <br />4567 Enterprise Street <br />CITY <br />410. STATE 411. <br />ZIP CODE 412. <br />Fremont <br />CA <br />94538 <br />::� +. '' r. %xM1l^I" ,,.'I , f y ,. "ce �11I <br />,Ill III �I #hh N�u I'1 (III II!III <br />111 ,1 „ ,�,1,, <br />1 !.1. ' s� .�. k... �.(IIIIIII !IIIIIIII VIII ILII ^ <br />TANK OPERATOR NAME <br />428-1. PHONE 428-2 <br />Quik Stop Markets, Inc. <br />510-657-8500 <br />MAILING ADDRESS <br />428-3 <br />4567 Enterprise Street <br />CITY <br />428-4 STATE 428-5 <br />ZIP CODE 428-6 <br />Fremont <br />CA <br />94538 <br />I! fia: ,rr^NII III IMI ",. ir. 1111 1 .,:.f <br />.. kfi3Ni+11 M f,G (III XIII III IIS Igu II 'I ^ 7m, <br />1 <br />�I <br />I <br />5h1 II ,„.,1 1'IIIIII ! (IIIIIII (IIII��IN +.dWr <br />TANK OWNER NAME <br />414. PHONE 415. <br />Quik Stop Markets, Inc. <br />510-657-8500 <br />MAILING ADDRESS <br />416. <br />4567 Enterprise Street <br />CITY <br />417. <br />STATE 418. <br />ZIP CODE 419. <br />Fremont <br />CA <br />94538 <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT <br />❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. <br />❑ 7. FEDERAL AGENCY <br />X 8. NON-GOVERNMENT <br />': 1�: 41 '�u"§i'i <br />C <br />III Y' d. �1 1� <br />TY (TK) HQ 44- <br />Call the State Board of Equalization, Fuel Tax Division, if there are questions. 421. <br />� 1 I III •� 1IhlI I 1 !IIIdIl1IVVV # millI �� j. <br />Isom rr m, �fjgrx;��I,,l14Ck- hr� y��I�l�1�lIIIµII�!IIIIII I�I��� IIh��I�1 yr -3^ 11�1ih 1GNNO <br />Issue permit and send legal notifications and mailings to: <br />,1 . .... <br />❑ 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 <br />For Public Agencies Only) <br />CERTIFICATION: I certify that the information provided <br />herein is true accurate and in full com liance with legal requirements. <br />ARPLJGANT SIGNATURE <br />DATE 424.PHONE <br />azs. <br />l t l <br />916 373-1166 <br />AP A T NAME (print) <br />426. <br />APPLICANT TITLE 427 <br />Dulcinea Covan <br />Com liance Manager <br />UPCF UST -A Rev. (12/2007) <br />