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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 /> TYPE OF ACTION 1.NEW"W. ❑ 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. FAGILTIINPORMAY?IUN <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> 3 (Agency Use Ordly) ('J <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3' <br /> QUIK STOP MARKET #148 <br /> BUSINESS SITE ADDRESS 103- CITY 104, <br /> 205 WEST LOCKEFORD STREET LODI <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4°3. Is the facility located on Indial Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes No <br /> II, PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 408. <br /> ADACHI INVESTMENT, LLC 415 396-6961 <br /> MAILING ADDRESS 409. <br /> r <br /> 1991 SUN MOR AVENUE <br /> CITY 410. STATE all. ZIP CODE 412. <br /> MOUNTAIN VIEW CA 94040 <br /> III.''�TANK'OPF�2ATUR INFORMATIbN� . ,M ..` <br /> TANK OPERATOR NAME 428-1. 1 PHONE 429-2 <br /> QUIK STOP MARKETS, INC. (510)657-8500 <br /> MAILING ADDRESS 429-3 <br /> 4567 ENTERPRISE STREET <br /> CITY 4284 STATE 428.5 ZIP CODE 428-6 <br /> FREMONT CA 94538 <br /> 'F TANK;OWNER�INFOR VIATION <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 417. STATE 418. ZIP CODE 419 <br /> FREMONT CA 94538 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT �❑ 55.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY IK 8.NON-GOVERNMENT <br /> ... ..�Zr . �,� <br /> STORAGE FEE ACCOUNT NUMBER y <br /> TY(TK)HQ 44- 0 1 $ 7 6 Call the State Board of Equalization,Fuel Tax Division,if there are questions. azl. <br /> .. r ,p!� OLDLRINF,ORMATION <br /> Issue permit and send legal notifications and mailings to: ,❑ 11.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> lK 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> ,VII.APPI;I��'A�'NT�SIGNATUIt�' ` � . <br /> �P. <br /> CERTIFICATION: I certify that the i formation provided herein is true,accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE TURE DATE 424. PHOS <br /> ✓/1 Se tember 8, 2009 510 445-2285 r. <br /> APPLICANT NAME(print) 426. APPLICANT TITLE <br /> MIKE KARVELOT, for Quik Stop Markets, Inc. DIRECTOR, ENVIRONMENTAL AFFAIRS <br /> UPCF UST-A Rev.(12/2007) °5 <br />