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1 y�y1 <br /> 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 P&k%f 116101 ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as FACHATY NAME or DBA-Doing Business As) 3. <br /> QUIK STOP MARKET #152 <br /> BUSINESS SITE ADDRESS 103• CITY 104• <br /> 1721-1 CHEROKEE LANE LODI <br /> FACILITY TYPE j? 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes irr4o <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> VERA E. MARTIN, c/o FAIRWAY MGMT. SVCS. 408 279-1033 <br /> MAILING ADDRESS 409. <br /> P.O. BOX 179 <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> WOODBRIDGE CA 95258 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1• PHONE 429-2 <br /> QUIK STOP MARKETS, INC. (510) 657-8500 <br /> MAILING ADDRESS 428-3 <br /> 4567 ENTERPRISE STREET <br /> CITY 428.4 1 STATE 428-5 ZIP CODE 429-6 <br /> FREMONT CA 94538 <br /> IV. TANK OWNER INFORMATION <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• 1 STATE 419. ZIP CODE 419• <br /> FREMONT CA 94538 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ❑ 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 1 1 18 7 16 1 3 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 /> E 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNA DATE 424• PHONE <br /> August 24, 2009 (510)445-2285 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> MIKE KARVELOT, for Quik Stop Markets, Inc. DIRECTOR, ENVIRONMENTAL AFFAIRS <br /> UPCF UST-A Rev.(12/2007) <br />