|
AMlIcitzn acinnmAoA rr�llanr InAY'cn anhat
<br />UNDERGROUND STORAGE TANKS ® FACILITY YANKS
<br />(ons p;ago par sl(p) I'ag,l J of
<br />TY Or nrTl n L I I, NCW AMYt►ttd1T U a RGNtaWW �Ct+Mff q 3•glAiVac CN w/o N A 7;9=67--097,0 r'I`
<br />(C roCA on, xUal em 41 Q A. At8NP110 MG WIT WcIN N%1FVa luc r v+4 0
<br />MY ,,,, ," Q i,TN+KRST+OVEO
<br />0 4-YEMP~ Viii CLOME , oa
<br />1. FACILITY ! 81T>c 1NF RMATI4N
<br />OUSINF'I NAMRISaenae,l 1TY)IAlyppyS.dwq� p FA (L io4 r
<br />Hernmertown Lane _ 0 1, CORPORATION Q s. COUNTY AGENCY'
<br />6USIN&S5— 1. GAS STATION M �, FpftM �� b, C MME�2CfAL [] 2. INDIVIDUAL Cj 0. STATE AGENCY,
<br />TYpV Q 2. DISTRIVUTOR Q 4, PROCESSOR [16. OTHER rot Q S. PAR rNCRSHIP Q 1, FEpERAL AGENCY'
<br />TOTAL NUMm EA Or TANKS la a Illy on Indian Ftornml on or •Ir o or-tAf 111-1--
<br />pUMI: agency: ntma or:upcMoOr of d'Mclon, WWI o, Ohre
<br />R Qvv%iNIN(! AT SITE Irus(I0ndo w1kh oponbi Ilu V8T (This la hho oonbcl parson lot Bw tonk Itcori q
<br />3 404 Q Yea 0 No 1103 +x
<br />II, PROPERTY OWNED INFORMATION
<br />Tokeakl Peter Kas)Ilma
<br />1416-948-0721
<br />MnIUIvG UIQ $TRCE A-' SSS
<br />69G Berry Avenue
<br />"
<br />CiTY +le
<br />STATE+Ir
<br />zIP COOF
<br />Los Alto9
<br />CA
<br />84022
<br />PROP �IkTY�WNC`R'TYPE [� 1. CORHOM71Z -R2INOI V I UAL ^U 4. L OCAL AGI NCY / DI sTRI0 G. STATE• EN
<br />A CY
<br />❑ 3. PARTNER8HIP 0 6. COUNTY AGENCY 0 7. FEDERAL
<br />+'
<br />Ili, TANK OWNER INFORMATION
<br />TAN]( OWNER NA,04-- " 414
<br />PHONEy)
<br />qu k StopMarkets. Inc.
<br />si4.497 8500
<br />h ,DNO Ort
<br />4567 Enterprso Street
<br />M �-
<br />CITY40
<br />BTATE All
<br />ZIP CODE
<br />Fremont
<br />CA
<br />84538
<br />_
<br />r&'lK OWNER TY—t — "j cojtFo`�tA-lion 2, thplVlpvAL 4'TE ST
<br />tOCALA6ENCY/GIS L. AAG&,vCv
<br />:a
<br />❑ 3. PARTNIERSHIP 4 6. COUNTY A13ENCY 7, FE06P.A. A(3;F(CY
<br />_
<br />IV, BOARD OF EQUALIZATION UST 5TORAPE FF -0 ACCOUNT NUMBER
<br />TY—QT K1HQ 44.01 7 -L=3-F-' Cal) (91,fs) 32 -9669 if wee ions arise
<br />V, PETROLEUM UST FINANCIAL, RESPONSIBILI
<br />'
<br />I
<br />INOICATa --b'T f;6 N3UR 0 4. swot 00 ��7. STAT • FUND 10. LOCAL GOVT MCCHANI4M�
<br />MCTNOD(S) Q 2. OUARANTFE ❑ 5, LETTER OF CREDIT Q 9, BTATI; FUND ✓w CFO LETTER Q 99, OTHCR:_•__-
<br />0 1. INSURANCR 0 6, 6X6MMON Q 9. STATE FUND & CD
<br />VI, LEGAL NOTIFICATION AND MAILING A4t)RESS
<br />vl
<br />C;� k anoic� io +Vknie Yrh'clt gddnio i7oZT4 bo usb0"7or m aai noufr4,l'ans rnd maillnp,
<br />,t+
<br />t roue nog fr;,u,�n, sno Wilkkod VAI ba Tali to NO 111nk Mar unlet, Dox I or 2 U 04004. Cy 1. FACILITY C 2 AAoD cRTY OWNER 03 TaI,K
<br />VII. APPLICANT SIGNATURE
<br />r..._
<br />Cnn�6umon - I crrliy Iwi A+,:Ue�W�N6o4 hirole IT 4vo a cwl,la w Iho uocl q- j my`%ppW,cQOe.
<br />_s
<br />�•—"
<br />S1yt1A?t kkT
<br />DA' t24
<br />PHONE
<br />N C Or AP LI.C�NT (print � " r%�
<br />(1; TFa'fi•' IPS -t ' Fc., C��i•����� ,t b—r
<br />TIT t� OF APPLICANT _ "-
<br />C cu�bw7tC.
<br />07
<br />STATE UST FACILITYNUMpCR(rerlw,luww4yl +)11
<br />1996UPGRAIECERTIFICATE NVMDgR(Farkc+,rnw,,rl
<br />"2a
<br />UPCF (11q� reviycd) Formerly SWRCE form A
<br />
|