Laserfiche WebLink
v <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 4W. <br /> (Cheek one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY dN. FACILITY ID# t. <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3- <br /> 7-Eleven 32190 <br /> BUSINESS SITE ADDRESS 103. CITY IN. <br /> 4943 S. Highway 99 Stockton <br /> FACILITY TYPE ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 4D3. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE are. <br /> Fredrich Enterprises. ( ) <br /> MAILING ADDRESS 409. <br /> 148 Fruit Ave <br /> CITY 410. 1 STATE 411. ZIP CODE 412. <br /> Patterson TX 95363 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4'-8-1. PHONE 4'-1-1-. <br /> 7-Eleven Inc. (916) 463-6776 <br /> MAILING ADDRESS 4'-8-3. <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 4'-8-4 STATE 4285. 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 /> CITY 417. STATE 418. ZIP CODE 419. <br /> Dallas TX 75221 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4m. <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 1 $ 19 16 1 1 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 021. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR 423. <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> C:j <br /> VIL APPLICANT SIGNATURE f <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements td<' <br /> APPLICANT SIGNATURE DATE 41+ PHONE 4s, <br /> (916) 463-6776y <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Ian Moorhead Environmental Compliance Manager <br /> UPCF UST-A Rev.(1212007)-1/2 www.unido".org <br />