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IED PROGRAM CONSOLIDATED FO (ty (y <br />I TANKS <br />UNDERGROUND STORAGE TANKS- FACIL yJ�purlD Qi <br />U I Page of <br />(one page per site) <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br />(Check one Rem only) ❑ 4. AMENDED PERMIT specify change local use only ❑ 8. TANK REMOVED <br />❑ &TEMPORARY SITE CLOSURE 400 <br />I. FACILITY/ SITE INFORMATION r <br />BUSINESS NAME(Same as FACILITY NAME or DBA- Doing Business Ax) 3 <br />FACILITY ID# <br />10 <br />FF <br />Tr <br />7 -Eleven 14117 <br />U <br />Z <br />v <br />NEAREST CROSS STREET 401 <br />FACILITY OWNER TYPE ❑ 4. LOCAL GENCY/DISTRICT' <br />2725 Count Club Blvd., Slocllon, CA <br />Z 1. CORPORATION El 5. COUNTY AGENCY' <br />❑ 2. INDIVIDUAL [16. STATE AGENCY' <br />BUSINESS 1. GAS STATION 3. FARM ❑ 5. COMMERCIAL <br />TYPE [12. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 403 <br />❑ 3. PARTNERSHIP [17. FEDERAL AGENCY' 402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />'If owner of UST is a public agency: name of supervisor of division, section or office <br />REMAINING AT SITE <br />trustlands? <br />which operates the UST (This is the contact person for the tank records.) <br />2 404 <br />❑Yes Z No 05 <br />406 <br />ll. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 408 <br />7 -Eleven, Inc. <br />702-270-7160 <br />MAILING OR STREET ADDRESS 409 <br />P.O. Box 711 Attn: Gasoline Acctg. <br />CITY ^10 <br />STATE 411 <br />ZIP CODE 412 <br />Dallas <br />TX <br />75221-0711 <br />PROPERTY OWNER TYPE Z 1. CORPORATION 2. INDIVIDUAL [14. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME ala <br />PHONE 415 <br />7 -Eleven, Inc. <br />702-27o-71so <br />MAILING OR STREET ADDRESS 416 <br />P.O. Box 711 Attn: Gasoline Acctg. <br />CITY 417 <br />STATE 418 <br />ZIP CODE 419 <br />Dallas 1 <br />TX <br />75221-0711 <br />TANK OWNER TYPE Z 1. CORPORATION C:12. INDIVIDUAL 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY ago <br />❑ 3. PARTNERSHIP [:15. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- 1 3 1 1 1 8 1 9 6 Call 916 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE Z 1. SELF-INSURED ❑ 4. SURETY BOND [-17. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />METHOD(s) ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ 8. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />1-13. INSURANCE ❑ 6. EXEMPTION [19. STATE FUND & CD 422 <br />Vl. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and mailing. <br />Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER (9 3. TANK 423 <br />OWNER <br />VII. APPLICANT SIGNATURE <br />Certification c that th ion provided herein is true and accurate to the best of my knowledge. <br />SIGNATURt QWrAPPLI <br />DATE 424 <br />PHONE 425 <br />- <br />702-270-7160 <br />1 <br />NAME OF A PLICA 'nt) 426 <br />TITLE OF APPLICANT 427 <br />Shane Partridge <br />Gasoline & Environmental Compliance Manager <br />STATE UST FACILITY NUMBER (Forlocal use only) 428 <br />1998 UPGRADE CERTIFICATE NUMBER (Far local use only) <br />429 <br />UPCF (1/99 revised) Formerly SWRCB Form A <br />