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Vol <br /> unli''lED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACRIrY CLOSURE 400' <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ b.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTS AT FACILITY w4 I FACILITY ID q _ 1. <br /> 2 (Agency Use Only) <br /> BUSINESS NAME(s .Fumy NAMEm,,A-who jmm) 3 <br /> Circle K Stores, No 2701205 <br /> BUSINESS SITE ADDRESS 103. CITY <br /> 16470 Cambrid a Lathrop <br /> FACILITY TYPE 0 L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4n3. Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands' ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE nae. <br /> Khinda, Hardell & Amarjit Singh Khinda Attn: Hardev Khinda 209-321-1632 <br /> MAILING ADDRESS 4oy <br /> 27000 S. Leeward Way <br /> CITY 410 LSTATE 411. <br /> ZIP CODE ate. <br /> Tracy CA 95304 <br /> IIL TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429.1. PHONE @9 <br /> Circle K Stores, Inc. (951) 270-5163 <br /> MAILING ADDRESS <br /> 136-3 <br /> Da5 East Rincon, Suite 1010 <br /> CITY 42W STATE 438-5 <br /> ZIP CODE 42es <br /> Corona CA 92879 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME - 414. PHONE 413, <br /> Circle K Stores, Inc. (951) 270-51631 <br /> MAIUNG ADDPMS 416. <br /> a55East Rincon, Suite 1CO <br /> CITY an. SigTE ate. CODE 419. <br /> Corona CA 92879 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 430. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 13 12 0 ] 3 I Call the State Bond 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 /> ❑ 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 certiq that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> A7PRAPP ICAN S NRS DATE 434. PHONE 42s. <br /> hGN tatti: a3 95I 270-5163 <br /> L CANT NAME(pain) 426. APPLICANT TITLE 427 <br /> Rex Abacan Environmental Compliance Manager <br /> UPCF UST-A Rev.(ID2007) <br />