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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 # I 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 4M STATE 41L ZIP CODE 412. Fremont CA 94538 III. TANK OPERATOR INFO TION . 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. 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 Call the State Board of Equalization, Fuel Tax Division, if there are questions. 421. VI. PERMIT HOLDER INFORMATION ,. 423 Issue permit and send legal notifications and mailings to: El1. FACILITY OWNER [:14. TANK OPERATOR X 3. TANK OWNER ❑ 5. FACILITY OPERATOR 406. SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) VII. APPLICANT SIGNATURE CERTIFICATION: I certify that the information provided herein is true, accurate, and in full compliance with legal requirements. PL T SIGNATURE DATE a24. PHONE 425. - (1 (916) 373-1166 APPLICANT NAME (print) 426. APPLICANT TITLE 427 Duldnea Covan Compliance Manager UPCF UST -A Rev. (12/2007)