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DI <br /> UNIFIED PROGRAM CONSOLIDATED FORM <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 <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACI,PCY °U0' FACILITY m# _ 1. <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Now or DBA-Doing Business As) 3 <br /> 7-Eleven 32190 <br /> BUSINESS SITE ADDRESS 103, CITY 104. <br /> 4943 S. Highway 99 Stockton <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Fredrich Enterprises. ( ) <br /> MAILING ADDRESS 49 <br /> 148 Fruit Ave <br /> CITY 410, STATE 411. <br /> ZIP CODE ate. <br /> Patterson 95363 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-t. PHONE 42e-z. <br /> 7-Eleven Inc. (916) 463-6776 <br /> MAILING ADDRESS 428x. <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 428-4. 1 STATE 428-5. <br /> ZIP CODE 428-6. <br /> Dallas TX 75221 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> 7-Eleven Inc. (800) 828-0711 <br /> MAILING ADDRESS 416. <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY417. 1 STATE 418. 1 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 1 9 1 6 1 1 Call the State Board of Equalization,Fuel Tax Division, f there are quest ons. 421' <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 4 <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required far Public Agencies Only) <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 TSSIGNATURE DATE 424 PHONE <br /> APPLICANT NAME(print) 4?s (916) 463-6776 <br /> APPLICANT TPIT,E <br /> Ian Moorhead Environmental Compliance Manager <br /> UPCF UST-A Rev.(12/2007)-1/2 w .unidocs.org <br />