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U :IED PROGRAM CONSOLIDATED F 1M <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) <br /> Page _ of <br /> TYPE OF ACTION <br /> (Check one dem only) ❑l.NEW SITE PERMIT ❑3.RENEWAL PERMIT ISS.CHANGE OF INFORMATION(Specify change- ❑7.PERMANENTLY CLOSED SITE <br /> [14.MENDED PERMIT 10091 use only) ❑B.TANK REMOVED 400 <br /> ❑6.TEMPORARY SITE CLOSURE <br /> I.FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# 1 <br /> Circle K Stores Inc.#2701205 <br /> BUSINESS SITE ADDRESS 401 FACILITY OWNER TYPE <br /> ® 1. CORPORATION ❑ 4. LOCAL <br /> YAGEN/DISTRICT' <br /> 16470 CAMBRIDGE ❑ 5. COUNTY AGENCY' <br /> BUSINESS TYPEEl2. INDIVIDUAL ❑ 6. STATE AGENCY' <br /> ®1.GAS STATION ❑ 3.FARM ❑S.COMMERCIAL ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 <br /> 02.DISTRIBUTOR ❑ 4.PROCESSOR ❑ 6.OTHER <br /> 403 <br /> TOTAL NUMBER OF TANKS Is fadlly on Indian Reservoir.or 'H owner of UST is a public agency:name of supervisor of <br /> REMAINING AT SITE tv"ands7 division,section or office which operates the UST. <br /> (This is the contact Person for the tank records.) <br /> 2 404 ❑Yes ®No 405 406 <br /> It.PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> KHINDA, HARDELL &AMARJIT SINGH KHINDA (510)245-5219 <br /> MAILING OR STREET ADDRESS 409 <br /> 27000 S. LEEWARD WAY <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> TRACY CA 95304 <br /> PROPERTY OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY f DISTRICT ❑ 6. STATE AGENCY 413 <br /> ❑ 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> 111.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Circle K Stores Inc. (909)270-5193 <br /> MAILING OR STREET ADDRESS 416 <br /> 495 East Rincon Ste 150 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Corona CA 92879 <br /> TANK OWNER TYPE ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 420 <br /> ® 1. CORPORATION ❑ 3. PARTNERSHIP ❑ 5. COUNTYAGENCY ❑ 7. FEDERALAGENCY <br /> TY(TK)HO 4 4 1 1 0 3 2 1 0 7 3 Call(916)322-9669 if questions arise 421 <br /> INDICATE METHODS) ❑ 1. SELF-INSURED ❑ URETY BON <br /> 4. SD 7. STATE FUND 10. LOCAL GOV=T MECHANISM <br /> ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND&CFO LETTER ❑99. OTHER: <br /> ® 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATEFUND&CD 422 <br /> Check one box to indicate which address should be Usetl for legal no0fica8ons and nailing. ❑ 1. FACILITY ❑ 2. PROPERTYOWNER ® 3. TANKOWNER 423 <br /> Legal notifications and railings volt be sent to the tank owner unless box 1 or 2 is checked. <br /> Certification: I cetiy that the information pnn idecl herein is true and accurate to the best of rrry knoWledge. <br /> SIGNATURE OF APP NT DATE /� ' 424 PHONE 425 11 <br /> V Q (909)270-5193 <br /> NAME OF APPLICA (prfrp TITLE IQF JPPUCANW426 <br /> Michelle Wilson West Ooast Environmental Compliance Manager <br /> STATE UST FACILITY NUMBER(For Axa/use only) 427 1 1998 UPGRADE CERTIFICATE NUMBER(For/oce/use on/y) 428 <br /> UPCF(1/99 revised) 5 Formerly SWRCS Form A <br />