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GIGr1 GOf1f2O AAA l+�1dIQ/11 11'IATGI'1 G/1 ^ � <br /> J V TA KS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page / of 7 <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> FA a 4/ ❑&TEMPORARY SITE CLOSURE 400 <br /> 124,4OL ITy 1 SI �INFORMATION <br /> -r�� ,F.s•, <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 3 FACJL1TY JP__fR. 1 <br /> Quik Stop Market#125 <br /> NEAREST CROSS STREET 401 FACILITY OWN R TYPE [:14.LOCAL GENCY/DISTRICT* <br /> Jacktone Road ® 1.CORPORATION [:15.COUNTY AGENCY* <br /> BUSINESS ® 1.GAS STATION [13.FARM ❑5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE ❑2.DISTRIBUTOR [14.PROCESSOR[16. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY* 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes ® No 405 406 <br /> IIM=PROPER'CY QWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> William Scharfen 415-821-4108 <br /> MAILING OR STREET ADDRESS 409 <br /> 26792 Palo Hills Drive <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Los Altos Hills CA 94022 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ®2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT [16.STATE AGENCY <br /> [13.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL 413 <br /> VIII TA► NlNER INFO2MATIGIN <br /> .< <br /> TANK OWNER NAME 414 PHONE 415 <br /> Quik Stop Markets, Inc. 510-657-8500 <br /> MAILING OR STREET ADDRESS 416 <br /> 4567 Enterprise Street <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Fremont CA 94538 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY [17. FEDERAL AGENCY <br /> 1ARIO :EGlUALIATION UST STORAGEF AtGOUNT NUMBER <br /> �e <br /> TY(TK) HQ 44-01 1 8 7 1 6 1 3 1 Call (916)322-9669 if questions arise 421 <br /> V,�PETROWUM USTF,INANCIAL RE.SPONS! ILII , <br /> INDICATE ❑1.SELF-INSURED ❑4.SURETY BOND ®7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE ❑5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER:_ <br /> ®3. INSURANCE ❑6.EXEMPTION [19.STATE FUND&CD 422 <br /> GAL NOTtkCAT ION ANP yl ING AADREaS <br /> Check one box to indicate which address should be used for legal notifications and mailing. 423 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK <br /> OWNER <br /> 77 777777,4 <br /> YII PPLI T SIGNA <br /> 0,. <br /> � <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNAT E PLIC T DATE <br /> 424 PHONE az5 <br /> OF <br /> 3 510-445-2285 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Mike Karvelot, for Quik Stop Markets, Inc. Director of Environmental Affairs <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />