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FIED PROGRAM CONSOLIDATED FO <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION X 1. NEW PERMIT ❑ 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. FACILITY INFORMATION <br />TOTAL NUMBER OF USTs AT FACILITY 404' <br />FACILITY ID # <br />3 <br />(Agency Use Only) <br />BUSINESS NAME (same as FACILITY NAME or DBA -Doing Business As) 3. <br />Quik Stop #152 <br />BUSINESS SITE ADDRESS 103, <br />CITY 104, <br />1721 S. Cherokee Lane #1 <br />Lodi <br />FACILITY TYPE x 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. <br />Is the facility located on Indian Reservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />Trust lands? ❑ Yes x No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />PHONE 408. <br />Quik Stop Markets, Inc. <br />510-657-8500 <br />MAILING ADDRESS 409. <br />4567 Enterprise Street <br />CITY 410. <br />STATE 411, <br />ZIP CODE 412. <br />Fremont 1 <br />CA <br />94538 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1, <br />PHONE 428-2 <br />Quik Stop Markets, Inc. <br />510-657-8500 <br />MAILING ADDRESS 428-3 <br />4567 Enterprise Street <br />CITY 428-4 <br />STATE 428-5 <br />ZIP CODE 428-6 <br />Fremont <br />CA <br />94538 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414, <br />PHONE 415. <br />Quik Stop Markets, Inc. <br />510-657-8500 <br />MAILING ADDRESS 416. <br />4567 Enterprise Street <br />CITY 417. <br />STATE 418. <br />ZIP CODE 419. <br />Fremont <br />CA <br />94538 <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. <br />❑ 7. FEDERAL AGENCY X 8. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- <br />1 1 Call the State Board of Equalization, Fuel Tax Division, if there are questions. 421. <br />VI. PERMIT HOLDER INFORMATION <br />Issue permit and send legal notifications and mailings to: ❑ 1. FACILITY OWNER ❑ 4. TANK OPERATOR 423 <br />X 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) 406. <br />VII. APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the information provided herein is true, accurate, and in full compliance with legal requirements. <br />T SIGNATURE <br />DATE 424, <br />PHONE 425. <br />(916) 373-1166 <br />AP T NAME (print) 426. <br />APPLICANT TITLE 427 <br />Dulcinea Covan <br />Compliance Manager <br />UPCF UST -A Rev. (12/2007) <br />