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/ ' Wor\ oonn_o Alla /`A\IC/ll Ir%ATCr% Or% <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page 1 of 7 <br /> Nommommmdl <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT [13.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVEp� <br /> ❑6.TEMPORARY SITE CLOSURE 1 400 O� <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY.ID# 0 1(D I Lf) Q (P -7 O 1 1 1 ..�' 1 <br /> Quik Stop Market#148 <br /> NEAREST CROSS STREET caZC LJC3 �$' LQC_Ke! C'i 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> North Church Street _ f�:(L, ® 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.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 /> 3 404 ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Alice Adachi 415-964-5217 <br /> MAILING OR STREET ADDRESS 409 <br /> 1991 Sun Mor Avenue <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> Mt. View CA 94040 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ®2. INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT [:16.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY [:17. FEDERAL 413 <br /> III.TANK OWNER INFORMATION <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 1 STATE 418 ZIP CODE 419 <br /> Fremont CA 94538 <br /> TANK OWNER TYPE ® 1.CORPORATION [:12.INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> [:13.PARTNERSHIP [:15.COUNTY AGENCY ❑7. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK) HQ 44-0 1 18 17 16 13 1 Call (916)322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED ❑4.SURETY BOND ®7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE ❑5. LETTER OF CREDIT [:18.STATE FUND&CFO LETTER ❑ 99.OTHER:_ <br /> ®3. INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <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 /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF PLI DATE 424 PHONE 425 <br /> 1 z - 7- Z,&c­6 510-445-2285 <br /> NAME OF APPLICANT(pant) 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 />