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03/09/04 TUE 13:10 FAX 714 428 8087 TOSCO MARRETING COMP&NY IM004 <br /> I' 'IFIED PROGRAM CONSOLIDATED F 1M �I <br /> 6) ( <br /> TANKS U <br /> UNDERGROUND STORAGE TANKS — FACILITY ��` I h l <br /> roDa Pam a� <br /> TYPE OF ACTION 01 NEW SITE PERMIT Page _ w _ <br /> (obese 6-0 dem 0*) ❑7,RENEWED PERMIT 05.CHANGE OF INFORMATION(Sped&4 ,Ige- ❑7.PERMANENTLY CLOSED SITE <br /> I]a.AMENDED PERMIT brei use pNy) <br /> CL03 ❑8.TANK REMOVEDo <br /> ❑5.TEMPORARY ST(E URE "o <br /> I.FACILrrY f srrE INFORMATION' <br /> BUSINESS NAME(� ea FACILITY NAME pDBA-DdnB Business Az) 3 ]7� <br /> '.Circle K Stores Inc. #2701205 <br /> BUSWESa SRS ADDRESS 401 RTME16470 CAMBRIDGE RATION 4. LOCALAGENCYIDLKTRICT'AL 5. COUNYYAGENCy- <br /> BUSINESSTYPE 101.GAS STATION ❑ 3,FARM 5.COMMRSHIP ❑ S. STATE AGENCY' <br /> LIZ DISTRIBUTOR ❑ 4,PROCESSOR ❑ 5.OTHER ❑ T FWERALAGENCY' 4p2 <br /> 607 <br /> MA REMAINING AT ITOTAL NUMBER O�F TANKS b Mollify on Indian Re4emtlan a M(o4ner d U$71s a W one agancy.lrefro of supervle0r of <br /> budamsY dlW�pn,im,chw or office wnitAaporatea"UST. <br /> .z 404 (This Is the contact Pecan for the m'k rewrds.I <br /> []Yes ®No 409 406 <br /> II.PROPERTYOWNER'INFORMATION <br /> PROPERTY OWNER NAME 4PI <br /> KHINDA, HARDELL&AMARJIT SINGH KHINDA PHONE 400 <br /> MANLINGORSTREETADDRE3a 408 (510)245-5219 <br /> 27000 S. LEEWARD WAY <br /> 410 <br /> TRACY CA 611 95304 412 <br /> PROPERTY OWNERTYPE 2. INDIVIDUAL <br /> ❑ 1. CORPDRATION 4, LOCALAGENCYIDISTRNCT ❑ B. STATE AGENCY 413 <br /> 3. PARTNERSHIP 5, COUNTYAGENCY ❑ 7. FEDFRALAGENCy <br /> IID TANK OWNER iNFORMATt01k< <br /> ..TANK OWNER NAME 41d <br /> Circle K Stores Inc- PHONE 415 <br /> MWUNGORBTREE,AoORESS 410 (909)270-5193 <br /> 495 East Rlncon Ste 150 <br /> CITY 417 <br /> Corona STATE 4 LPC 410 <br /> CA 92879 <br /> TANK OWNt:R TYPE 2. INDIVIDUAL <br /> ® I. DORPOMTK)N ❑ 4, LOCALAGENCy1019TRICT 9, STATEAGENCY 420 <br /> 3. PARRaERSWIP ❑ 5.COUNTYAGI;NCV 7, FEDERAL AGENCv <br /> T1'('1A)NQ 4 4 1 1 0 1 9 2 07 3 Call 916 322-%69 if <br /> ( ) questions arse <br /> T.ETN0ol8) '❑ 1. SELF-INSURED ❑ 4. SURETY BOND '.I ... ,,, <br /> ❑ 2. GUARANTEE 7.STATE' "'10.LaDAC Gov=T MECHAHISU .. <br /> IDI ❑ 5, LETTER OF CREOR B. STATE FUND a CFO LETTER 93, OTHER- <br /> - <br /> 3.3. INSURANCE ❑ S. E%EM"ON <br /> S.STATE FUND a CD <br /> 77-n :. <br /> CJ10d1 and btaMlAdieilbAMINIi eddn ShOUld W wed 74fl <br /> L4pal rlo0su0ans and rtellln(p wW oe sent m the leek oarlaf�an Wx I or Is needmd. ❑ 1. FACIIhY ❑ 2. PROPERTY OWNER <br /> 3.TANTE oOJNER..ss3 <br /> De,vilo or: I eft"Ibt the wornwor,mvided he Is Ws and erCinb to the Dari d my knoabage. <br /> 810WlTURE OF AP T �� <br /> 424 PHONE �S <br /> NAaE OF APPLI rPnnD - V Q (909)270-5193 <br /> Michelle Wilson TITLE 426 <br /> West ast Environmental Compliance Manager <br /> STATE UST FACILITY NUMBER(For bmi use 0") 427 ISN UPGRADECERTIFIUTENUMBER(FwiowlmeaWy) 420 <br /> UPCF OM Mvisad) 5 <br /> Formerly SWRCR Form A <br />