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IED PROGRAM CONSOLIDATED FOR �b <br />`n VoyTANKS <br />UNDERGROUND STORAGE TANKS - FACI[1TY t.�'Q <br />(one page per site) Page _ of <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ T.PERMANENTLY CLOSED SITE <br />(Check one Hem only) ❑ 4. AMENDED PERMIT specify change local use only ❑ 8. TANK REMOVED <br />❑ &TEMPORARY SITE CLOSURE 400 <br />� A <br />I. FACILITY / SITE INFORMATION P n 011-)c, -72. <br />BUSINESS NAME(S..c as FACILITY NAME or DBA- Doing Business As) 3 FACILITY 01 1 <br />7 -Eleven 32262 <br />FACIL OWNER TYPE ®4. LOCAL GENCY/DISTRICT" <br />NEAREST CROSS STREET 40, <br />® 1. CORPORATION ❑ 5. COUNTY AGENCY - <br />2360 W. Grant) Line Rd., Trac , CA <br />®1. GAS STATION 3. FARM 5. COMMERCIAL ❑ 2. INDIVIDUAL [16. STATE AGENCY' <br />BUSINESS <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR [16. OTHER 403 ❑ 3. PARTNERSHIP [:17. FEDERAL AGENCY" qoz <br />TOTAL NUMBER OF TANKS Is facility on Indian Reservation or 'If owner of UST is a public agency: name of supervisor of division, section or office <br />which operates the UST (This is the contact person for the tank records.) <br />REMAINING AT SITE trustlands? 406 <br />3 404 ❑ Yes ® No 405 <br />II. PROPERTY OWNER INFORMATION <br />4m PHONE 408 <br />PROPERTY OWNER NAME <br />702-270-7160 <br />7 -Eleven, Inc. 409 <br />MAILING OR STREET ADDRESS <br />P.O. Box 711 Attn: Gasoline Accta. 410 STATE 411 ZIP CODE 412 <br />CITY <br />1 TX 75221-0711 <br />Dallas ISTRICT . STATE AGENCY <br />PROPERTY OWNER TYPE ®1. CORPORATION <br />7. <br />O 3. PARTNERSHIP EJ 5. COUNTY AGENCY ❑ FEDERAL 413 <br />III. TANK OWNER INFORMATION <br />414 PHONE 415 <br />OWNER NAME <br />702-270-7160 <br />ven, Inc. <br />OR STREET ADDRESS <br />ETANK <br />E416NG <br />BOX711 Attn:GasolineAcct <br />STATE 416 ZIP CODE9 <br />41 <br />TX 75221-0711 <br />as 6. STATE AGENCY azo <br />TANK OWNER TYPE ®1. CORPORATION Lj 4. LOCAL AGENCY / DISTRICT O <br />O 3. PADRTNERSHIP ❑ 5. COUNTY AGENCY 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />8 9 6 Call 916 322-9669 if questions arise 421 <br />TY HO 44- 3 1 <br />TK <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE ® 1. SELF-INSURED 1714. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />METHOD(s) ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />422 <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 />be to the lank owner unless box 1 or 2 is checked. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK 423 <br />Legal notifications and mailings will sent <br />OWNER <br />VII. APPLICANT SIGNATURE <br />Certification I c that lh n provided herein is true and accurate to the best of my knowledge. 424 PHONE 425 <br />SIGNATUR PPLI DATE <br />702-270-7160 <br />4n <br />426 <br />NAME OF PLICA 'nt) <br />TITLE OF APPLICANT <br />Gasoline &Environmental Compliance Manager <br />Shane Partridge <br />429 <br />428 <br />STATE UST FACILITY NUMBER (For local use only) <br />1998 UPGRADE CERTIFICATE NUMBER (For local use only) <br />UPCF (1/99 revised) Formerly SWRCB Form A <br />