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FIED PROGRAM CONSOLIDATED FO . - � 6/7�1 If <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INF ON <br /> (One form per facility) <br /> TYPE OF ACTION X I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Checkone item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404- FACILITY ID# 1 <br /> 2 (Agency Use Only) <br /> BUSINESS NAME(Somas FACILITY NAME or DBA-Doing Business As) 3. <br /> 7-Eleven #14117 <br /> BUSINESS SITE ADDRESS 103. CITY 104, <br /> 2725 Country Club Blvd. Stockton <br /> FACILITY TYPE x 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION d03, Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes x No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408. <br /> 7-Eleven Inc. 805-523-2949 <br /> MAILING ADDRESS 409. <br /> PO Box 711 <br /> CITY 410. STATE 411, ZIP CODE 412. <br /> Dallas TX 75221 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428.2 <br /> 7-Eleven Inc. 805-523-2949 <br /> MAILING ADDRESS 423-3 <br /> PO Box 711 <br /> CITY 423-4 STATE 428-5 ZIP CODE 428.6 <br /> Dallas TX 75221 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 7-Eleven Inc. 805-523-2949 <br /> MAILING ADDRESS 416 <br /> PO Box 711 <br /> CITY 417. 1 STATE 418. ZIP CODE 419, <br /> Dallas TX 75221 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY X 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 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: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> X 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE _ <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> T SIGNATURE DATE 424 PHONE - 425. <br /> L 3- u -l0 916 373-1166 <br /> APPrMART NAME(print) 426 APPLICANT TITLE - 427 <br /> Dulcinea Webb-Covan Compliance Manager <br /> UPCF UST-A Rev.(12/2007) <br />