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_AWFIED PROGRAM CONSOLIDATED FO <br />TANKS lqw <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(One page per site)4, _ j p4ge l of 7 <br />TYPE OF ACTION ❑ 1. NEW PERMIT ❑ 3. RENEWAL PERMIT ❑ 5. CHANGE OF INFORMATION r_❑ 7 rERMANENTLY CLOSED SITE 400. <br />(Check one item only) ❑ 4. AN.ENDED PERMIT (Specify change) U $ TANK RRMOp ID & . <br />i <br />❑ 6. TEMPORARY SITE CLOSURE <br />I. FACILITY/SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3. <br />FACILITYFA <br />" <br />1 <br />uik StopMarket #148 <br />gic3 - <br />NEAREST CROSS STREET 401. <br />FACILITY OWNER TYPE 4. LOCAL AGENCY/DISTRICT* 402. <br />North Church Street <br />® 1. CORPORATION ❑ 5. COUNTY AGENCY* <br />❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />BUSINESS ® 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL 403. <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR [16. OTHER <br />❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* <br />TOTAL NUMBER OF TANKS 404. <br />Is facility on Indian Reservation 405. <br />* If owner of UST is a public agency: name of supervisor of division, section or 406. <br />REMAINING AT SITE <br />or trust lands? <br />office which operates the UST. (This is the contact person for the tank records.) <br />3 <br />❑ Yes ® No <br />H. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407. <br />PHONE 408. <br />Alice Adachi <br />415-964-5217 <br />MAILING OR STREET ADDRESS 409. <br />1991 Sun Mor Avenue <br />CITY 410. <br />STATE 411. <br />ZIP CODE 412. <br />Mt. View 1 <br />CA <br />94040 <br />PROPERTY OWNER TYPE ❑ 1. CORPORATION ® 2. INDIVIDUAL El 4. LOCAL AGENCY/ DISTRICT [:16. STATE AGENCY 413. <br />[13. PARTNERSHIP [15. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />PHONE 415. <br />Quik Stop Markets, Inc. <br />(510) 657-8500 <br />MAILING OR STREET ADDRESS 416. <br />4567 Enterprise Street <br />CITY 417. <br />STATE 418. <br />ZIP CODE 419. <br />Fremont <br />CA <br />94538 <br />TANK OWNER TYPE ® 1. CORPORATION ❑ 2. INDIVIDUAL [:14. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY 420. <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- 1 0 1 1 1 8 1 7 1 6 1 3 1 Call 916 322-9669 if questions arise 421. <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE METHOD(s) ❑ I. SELF-INSURED ❑ 4. SURETY BOND ® 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM 422. <br />[12. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />® 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and mailing. <br />Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY [:12. PROPERTY OWNER ® 3. TANK OWNER 423. <br />VII. APPLICANT SIGNATURE <br />Certification: I certify that the information provided herein is true and accurate to the best of my knowledge. <br />SIGNATURE OF APP ICANT DATE 424. <br />PHONE 425. <br />'�� 1 <br />(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 (Agency use only) 428. 1998 UPGRADE CERTIFICATE NUMBER (Agency use only) 429. <br />(See Data Element 1, above. <br />UPCF Hwfwrc-a (1/99) -1/2 http://www.unidocs.org Rev. 02/16/00 <br />