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FEB-07-2001 WED 03:44 PM Q IK STOP MKTS INC MX NO. 51U65(1b44 <br /> j0f%#--M l�I 1*A 0--iii InA,TV-n <br /> TANKS <br /> UNDERGROUND STORAGE TANKS W FACILI,04OR3/13D <br /> (ono page per site) Page-L,_of I_ <br /> 7.PERMANENTLY CLOSED 511 E <br /> TYPE OF ACTION D 1.NEW SITI=PERMIT 3,Rr--i Pr-RMIP []S.CHANGE OF INFORMATION B.TANK REMOVED <br /> (Chock oils Isom only) ❑4.AMCNDED PERMIT spocify chunor local uoo only - ❑ <br /> Q G.TEMPORARY SITE CLOSURE -- 400 <br /> "T FACILITY/SITE INFORMATION <br /> BUSINESS NAMt:(^ S.m:c as FA01Wry NAME or 00A-DMnd t3usGro55 A;:) 3 FACILITY IDS a <br /> Quik Stop Market#13? ° pACILETY OW®TYPE ❑4.LOCAL GENCYlDISTRICT" <br /> NEAREST Cli SI'REET <br /> Mariners D(IVO i� 1.CORPORATION ❑5.COUNTY AGENCY' <br /> 1.GAS STATION ❑3.FARM ❑5.COMML(?CIAh ❑ 2.INDIVIDUAL ❑6.STATE AGENCY" <br /> BUSINESG 403 3,PARTNERSHIP Q 7. FEDERAL AGENCY" ^02 <br /> TYPE Q 2.DISTRIBUTOR [14.PROCESSOR❑G. OTHER ❑ <br /> TOTAL NUMBI R O�TANKS Is facility on Indian Reservation or "u owner of UST Ie a public agency:name of supon for I e tank on,re rds or office <br /> trustlands? which operalos file UST(T'hls I6 ttu�contact por•on for the tank records.) <br /> REMAINING AT SI'TL• 405 A06 <br /> aon <br /> 3 [l Yt;s No <br /> PROPERTY OWNER INFORMATION <br /> aol PHONE noG <br /> PROPERTY OWNEK NAME 4I596 <br /> Alice Adachi ^GG <br /> MAILING OR STREET ADDRESS <br /> 1991 Sun Mor Avenue 410 STATE 411 ZIP CODE 412 <br /> CITY +T 94040 <br /> Mountain View CA <br /> PROPERTY OWNER TYPE ❑1•GORFARATION l�2.INDIVIDUAL [14,LOCAL AGENCY/DISTRICT U 6.STATE AGENCY 41a <br /> ❑3.PARTNERSHIP EI 5.COUNTY AGENCY ❑7.FFDERAL <br /> Ill.TANK OWNER INFORMATION <br /> -- 41g PHONE 41G <br /> TANK OWNER NAME 510-657-8500 <br /> Quik Stop Markets, Inc._ 41G <br /> MAILING UK STREET ADDRESS <br /> 4567 Fntar rise Street„^ 417 STATE 418 �ziPODE 4t9 <br /> CITY8 <br /> Fremont _ �A °2G <br /> TANK OWNER 1'YPE� i.CORPORA'T'ION ❑2•INDIVIDUAL ❑ L4 OCAL AGENCY/DISTRICT G.STATE AGENCY <br /> [13.PARTNERSHIPr ❑5.COUNTY AGENCY ©7.FEDERAL AGENCY <br /> IV. OARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK) HQ 44-t7 1 8 7 6 3 <br /> Call (916)322-9669 if questions arise A21 <br /> V. PETROLEUM UST FINANCIAL_RESPONSIBILITY <br /> INDICATE [ 1.SELF-INSURED ❑A.SURkiY BOND <br /> 7.STATE FUND ❑ 10.LOCAL GOVT MCCEIANISM <br /> METHODW ❑2.GUARANTEE ❑5. LETTER OF CRRDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER;__ 422 <br /> ®3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CP �. <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> ' 423 <br /> Gheck one box to indlceto wliich addross should bo usod for legal nollbcalions and moiling. 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK y <br /> Lopl naliAcoliOnS and muilinos will bo cont to the tank ownor unless box i or 2 is checked. Q <br /> nes NP41 �---�- Vlt,APPLICANT SIGNATURE <br /> Ccrlilication 1 sonify A1ut tho Inforni ion provided Iwrein Ie true and nccurato to ti 10 best of my knowiodge. <br /> DATE 424 PHONE nz5 <br /> 51CGNATURE O� Fes/ PLICAN 510-445-2285 <br /> 420 TITLE OF APPLICANT 427 <br /> NAME OF APPLICANT(print) Director of Environmental Affairs <br /> Mike Karvelot, for Quik Stop Markets, Inc. ^29 <br /> STATk UST FACILITY NUMBER tEorlocd uSaonly) 00 1998 UPGRADE CERTIFICATE NUMBER(For local use only) <br /> �10 <br /> Formerly SWRCB Form A <br /> UPCF(1199 revlscd) • • <br />