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r ry� <br /> 77 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility <br /> TYPE OF ACTION ❑ 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 /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# Hal <br /> 2 (Agency Use Only) <br /> BUSINESS NAME(Sarne as FACILITY NAME or DBA—Doing Business As) 3 <br /> QUIK STOP MARKET #120 <br /> BUSINESS SITE ADDRESS 103• CITY 104. <br /> 9321 THORNTON ROAD STOCKTON <br /> FACILITY TYPE 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403• Is the facility located on India Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes E No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408• <br /> EDWARD & PAULINE YANG 510) 261-1122 <br /> MAILING ADDRESS 409, <br /> P.O. BOX 1462 <br /> CITY 410• 1 STATE 411. ZIP CODE 412 <br /> ALAMEDA CA 94501 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> QUIK STOP MARKETS, INC. (510) 657-8500 <br /> MAILING ADDRESS 428-3 <br /> 4567 ENTERPRISE STREET <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> FREMONT ICA 94538 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415 <br /> QUIK STOP MARKETS, INC. (510) 657-8500 <br /> MAILING ADDRESS 416 <br /> 4567 ENTERPRISE STREET <br /> CITY 417 1 STATE 41a. ZIP CODE 419 <br /> FREMONT CA 94538 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT [1 55.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY e8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 10 1 1 1817161 3 T 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: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> e.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 inf2irmation prpvided herein is true accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE `7. � DATE <br /> ata. PHONE 425. <br /> /1 MAY 26, 2009 (510)445-2285 <br /> APPLICANT NAME(print) 426• APPLICANT TITLE 427 <br /> MIKE KARVELOT, for Quik Stop Markets, Inc. DIRECTOR, ENVIRONMENTAL AFFAIRS <br /> UPCF UST-A Rev.(12/2007) <br />