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AL <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION -FACILITY INFORMATION <br /> (One form per facility) <br /> 4u0. <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item onAt ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4n4. _ t <br /> FACILITY ID# _ <br /> 2 (Agency Ose Only) <br /> 9. <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) <br /> 7-Eleven 14117 <br /> BUSINESS SITE ADDRESS 103' CITY IU4 <br /> 2725 Country Club Dr. Stockton <br /> 4U5. <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 401 Is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME Oar. PHONE 408. <br /> 7-Eleven Inc. (916) 463-6776 <br /> 409. <br /> MAILING ADDRESS <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 410. STATE 411. ZIP CODE al'. <br /> Dallas TX 75221 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> 7-Eleven Inc. (916) 463-6776 <br /> 428-3. <br /> MAILING ADDRESS <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 428-4. STATE 428-6. ZIP CODE 428-6. <br /> Dallas TX 75221 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 TPHONE 415, <br /> 7-Eleven Inc. (800) 828-0711 <br /> MAILING ADDRESS ale. <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 417. STATE 41 a. 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 ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 13 1 1 18 9 6 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421' <br /> VI. PERMIT HOLDER INFORMATION <br /> 423. <br /> Issue permit and send legal notifications and mailings to: El 1.FACILITY OWNER [14.TANK OPERATOR <br /> Z 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 446" <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 4u. <br /> (916) 463-6776 <br /> APPLICANT NAME(print) 4'-6 APPLICANT TITLE 427 <br /> Ian Moorhead Environmental Compliance Manager <br /> UPCF UST-A Rev.(1212087)-1/2 www.unidomorg <br />