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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I.NEW PERMIT ® 5.CHANGE OF INFORMATION 4m <br /> (Check am item only) ❑ 7.PERMANENT FACILITY CLOSURE <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY °M FACILITY IDN _ t <br /> TWO (Ag Use Only) <br /> BUSINESS NAME(s u FACusry NAMEwoaA-oAggaamn4A,) 3 <br /> Circle K Store No. 2701205 <br /> BUSINESS SITE ADDRESS 1o3. CITY la. <br /> 16470 Cambridge Lathrop <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 401 Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4,PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 4013. <br /> Khinda, Hardell & Amarjit Singh Khinda (209) 321-1632 <br /> MAILING ADDRESS 4013 <br /> 27000 South Leeward Way <br /> CITY 410. STATE 41 <br /> ZIP CODE 41+. <br /> Tracy CA 95304 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4'-11-1 PHONE 43-+ <br /> Circle K Stores Inc. (951) 270-5193 <br /> MAILING ADDRESS 4211.3 <br /> 495 East Rincon Street, Suite 150 <br /> CITY 42114 STATE 4x1.5 <br /> ZIP CODE 42e-6 <br /> Corona CA 92879 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 414. PHONE 415, <br /> Circle K Stores Inc. (951) 270-5193 <br /> MAILING ADDRESS 416 <br /> 495 East Rincon Street, Suite 150 <br /> CITY 417. STATE 419. ZIP CODE 41v. <br /> Corona CA 82879 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Ty(TK)HQ 44- 10 3 2 0 7 3 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VL PERNIIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER4D <br /> ® 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 7067 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the informationrovided herein Is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 4x4 PHONE 413. <br /> 111/7/08 (951) 270-5193 <br /> APPLICANT N. ME(prinq 4x6. APPLICANT TILE axr <br /> Rich Gossett Environmental Compliance manager <br /> UPCF UST-A Rev.(I V2007) <br /> l <br />