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IED PROGRAM CONSOLIDATED FO UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-FACILITY INFORMATION (One form per facility) TYPE OF ACTION X 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT I. FACILITY INFORMATION TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# _ _ 1 3 (Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. Quik Stop #148 BUSINESS SITE ADDRESS 103. CITY 104. 205 W. Lockeford Street Lodi FACILITY TYPE x 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes x No H. PROPERTY OWNER INFORMATION PROPERTY OWNER NAME 407. PHONE 408. Quik Stop Markets, Inc. 510-657-8500 MAILING ADDRESS 409. 4567 Enterprise Street CITY 410. STATE 411. ZIP CODE 412, Fremont CA 94538 III. TANK OPERATOR INFORMATION TANK OPERATOR NAME 428-1. PHONE 428-2 Quik Stop Markets, Inc. 510-657-8500 MAILING ADDRESS 428-3 4567 Enterprise Street CITY 428-4 STATE 428-5 ZIP CODE 428-6 Fremont CA 94538 IV. TANK OWNER INFORMATION TANK OWNER NAME 414. PHONE 415. Quik Stop Markets, Inc. 510-657-8500 MAILING ADDRESS 416. 4567 Enterprise Street CITY 417. 1 STATE 418. ZIP CODE 419. Fremont CA 94538 OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. ❑ 7.FEDERAL AGENCY X 8.NON-GOVERNMENT V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. VI.PERMIT HOLDER INFORMATION Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 X 3.TANK OWNER ❑ 5.FACILITY OPERATOR SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. VII.APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. APPLICANT SIGNATURE DATE 424. PHONE 425. 9-11-09 (916) 373-1166 APPLICANT NAME(print) 426. APPLICANT TITLE 427 Dulcinea Webb Compliance Manager UPCF UST-A Rev.(12/2007)