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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYP;item <br /> N ❑ 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Checy) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Sum as MaLITY NAME or DBA--Doing Businm As) 3, <br /> QUIK STOP MARKET#125 <br /> BUSINESS SITE ADDRESS 103• CITY 104, <br /> 1580 WEST MAIN STREET RIPON <br /> FACILITY TYPE Wrl.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on IndaiReservation or 405' <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes (a No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408• <br /> SCHARFEN EXEMPT MARITAL DEDUCTION TRUST 650 941.4108 <br /> MAILING ADDRESS 40, <br /> 26792 PALO HILLS DRIVE <br /> CITY 417 STATE 411. ZIP CODE 412 <br /> LOS ALTOS HILLS CA 94022 <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 428-3 <br /> 4567 ENTERPRISE STREET <br /> CITY 428.4 1 STATE 428-5 ZIP CODE 428-6 <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 41 STATE 418. ZIP CODE 419, <br /> FREMONT CA 94538 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑�,/5.COUNTY AGENCY El 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY (Q 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1011181716131 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 /> e3.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 ulrements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 425. <br /> APRIL 8, 2010 1 (510)445-2285 <br /> APPLICANT NAME(print) 426. 1 APPLICANT TITLE 427 <br /> MIKE KARVELOT, for Quik Stop Markets,Inc. DIRECTOR, ENVIRONMENTAL AFFAIRS <br /> r-7 <br /> UPCF UST-A Rev.(12/2007) <br /> ,g 3 <br />