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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK C <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION X,, <br /> (One form per facility) <br /> TYPE OF ACTION OKI.NEW I?SAd E FbAPI (:15.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404• FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Businas As) 3. <br /> QUIK STOP MARKET#144 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 7272 WEST LANE STOCKTON <br /> FACILITY TYPE K1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes irg. <br /> II. PROPERTY OWNER,INFORMATION <br /> PROPERTY OWNER NAME 407_ PHONE 408. <br /> KASHIMA FIVE, LLC 415 948-0721 <br /> MAILING ADDRESS 409 <br /> 1009 BLACKFIELD WAY <br /> CITY 410• STATE 411• ZIP CODE 412. <br /> MOUNTAIN VIEW CA 94040 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428-2 <br /> QUIK STOP MARKETS, INC. (510) 657-8500 <br /> MAILING ADDRESS aza s <br /> 4567 ENTERPRISE STREET <br /> CITY 428-4 STATE 428-S ZIP CODE 428-6 <br /> FREMONT CA 94538 <br /> IV. TANG OWNER INFORMATION <br /> � <br /> TANK OWNER NAME ala. PHONE 415. <br /> QUIK STOP MARKETS, INC. (510) 657-8500 <br /> MAILING ADDRESS 416_ <br /> 4567 ENTERPRISE STREET <br /> CITY an. STATE 418, ZIP CODE 419. <br /> FREMONT CA 94538 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 55.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY lK a.NON-GOVERNMENT <br /> V. BOARD OF I13QUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> �. TY(TK)HQ 44- 0 1 8 7 6 3 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421• <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ,❑., 11.FACILITY OWNER C14.TANK OPERATOR 423 <br /> I!7 s.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the inf mation provided herein is true,accurate,and in full com liance with legal requirements. <br /> APPLICANT SIGNATURE DATE424• PHONE 425. <br /> September 1, 2009 510 445-2285 <br /> APPLICANT NAME(print) <br /> 426- APPLICANT TITLE 427 <br /> MIKE KARVELOT, for Quik Stop Markets, Inc. DIRECTOR, ENVIRONMENTAL AFFAIRS <br /> UPCF UST-A Rev.(12/2007) ` <br />