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'WnFIED PROGRAM CONSOLIDATED FOVM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION X 1. NEW PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 400. <br />(Check one item only) ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID # L <br />3 (Agency Use Only) <br />BUSINESS NAME (same as FACILITY NAME or DBA- Doing Business As) 3. <br />Quik Stop #124 <br />BUSINESS SITE ADDRESS 103. CITY 104. <br />505 N. Main Street Manteca <br />FACILITY TYPE x 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br />M 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER Trust lands? ❑ Yes x No <br />PROPERTY OWNER NAME <br />407_ <br />PHONE <br />408. <br />Quik Stop Markets, Inc. <br />510-657-8500 <br />MAILING ADDRESS <br />409, <br />4567 Enterprise Street <br />CITY <br />410. STATE 411. <br />ZIP CODE <br />412, <br />Fremont <br />CA <br />94538 <br />III; "ii'A� OPERATOR &#3RiATIQN <br />TANK OPERATOR NAME <br />428-1. <br />PHONE <br />428-2 <br />Quik Stop Markets, Inc. <br />510-657-8500 <br />MAILING ADDRESS <br />428-3 <br />4567 Enterprise Street <br />CITY <br />428-4 STATE 428-5 <br />ZIP CODE <br />428-6 <br />Fremont <br />CA <br />94538 <br />t <br />IV. T <br />OWI INFQRMA'TIC1N <br />TANK OWNER NAME <br />414. <br />PHONE <br />415. <br />Quik Stop Markets, Inc. <br />510-657-8500 <br />MAILING ADDRESS <br />416. <br />4567 Enterprise Street <br />CITY <br />a17. <br />STATE 418. <br />ZIP CODE <br />419. <br />Fremont <br />CA <br />94538 <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT <br />❑ 5. COUNTY AGENCY <br />❑ 6. STATE AGENCY <br />420. <br />❑ 7. FEDERAL AGENCY <br />X 8. NON-GOVERNMENT <br />TY (TK) HQ 44- 1 I I 1 1 I I Call the State Board of Equalization, Fuel Tax Division, if there are questions. 421. <br />UPCF UST -A Rev. (12/2007) <br />