Laserfiche WebLink
FIED PROGRAM CONSOLIDATED FO-49Ut) / q 112-10 <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (One page per site) ;_Page l of 7 <br /> TYPE OF ACTION ❑1.NEW PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION [17.PERMANENTLY CLOSED SITE 400. <br /> (Check one item only) ❑4.AMENDED PERMIT (Specify change) ❑8.'LtAINK;R$MOVEA <br /> ❑6.TEMPORARY SITE CLOSURE + °3 1: 59 <br /> L FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. FACILITY <br /> ID# FA 1 <br /> Quik Stop Market#152 cI0 <br /> NEAREST CROSS STREET 401. FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT* 402, <br /> Almond Drive ®1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS ®1.GAS STATION ❑3.FARM [:15.COMMERCIAL 403. [12.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR [:16.OTHER [13.PARTNERSHIP [:17.FEDERAL AGENCY* <br /> TOTAL NUMBER OF TANKS 404. Is facility on Indian Reservation 405. *If owner of UST is a public agency: name of supervisor of division, section or 406 <br /> REMAINING AT SITE or trust lands? office which operates the UST. (This is the contact person for the tank records.) <br /> 3 ❑Yes ®No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Vera Martin 408-279-1033 <br /> MAILING OR STREET ADDRESS 409. <br /> 659 College Drive <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> San Jose CA 95128 <br /> PROPERTY OWNER TYPE El 1.CORPORATION ®2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT E16.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <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 ❑5.COUNTY AGENCY [17.FEDERAL AGENCY <br /> IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1 0 1 1 8 1 7 1 6 1 3 1 Call 916 322-9669 if questions arise 421. <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑1.SELF-INSURED ❑4.SURETY BOND ®7.STATE FUND ❑10.LOCAL GOVT MECHANISM 422 <br /> ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑99.OTHER: <br /> ®3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD <br /> VI.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY [:12. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII.APPLICANT SIGNATURE <br /> Certification: I certify that the information provided he in is true and acgrate to the best of my knowledge. <br /> SIGNATURE OF APPLICAN DATE 424_ PHONE 425. <br /> -- /� August 23,2002 (510)445-2285 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427. <br /> Mike Karvelot,for Quik Stop Markets,Inc. Director of Environmental Affairs <br /> STATE UST FACILITY NUMBER(Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99)-1/2 http://www.unidocs.org Rev.02/16/00 <br />