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IED PROGRAM CONSOLIDATED FOR bilfil <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(one page per site) Page of <br />TYPE OF ACTION ❑ I. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT 0 5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br />(Check one item only) ❑ 4. AMENDED PERMIT specify charge local use only ❑ 8. TANK REMOVED <br />❑ 6.TEMPORARY SITE CLOSURE 400 <br />I. FACILITY / SITE INFORMATION P�'� L� 2 3 2 3 <br />BUSINESS NAME(SaIness FACILITY NAME or DBA- Doing Business As) 3 FACILITY D# 051 <br />L/ /\ <br />7 -Eleven 17334 <br />401 FACILITY OWNER TYPE ❑ 4. LOCAL GENCY/DISTRICT' <br />NEAREST CROSS STREET <br />4501 Pershin AVe, SfOCkton, CA Z 1. CORPORATION ❑ 5. COUNTY AGENCY' <br />BUSINESS 1. GAS STATION 3. FARM ❑ 5. COMMERCIAL ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY' <br />TYPE ❑ 2. DISTRIBUTOR [14. PROCESSOR [16. OTHER 403 ❑ 3. PARTNERSHIP ❑ 7. 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 aoa <br />❑Yes Z No 4os <br />406 <br />II. 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 410 STATE 411 ZIP CODE 412 <br />DallasTX 75221-0711 <br />PROPERTY OWNER TYPE Z 1. CORPORATION ❑ 2. INDIVIDUAL Lj 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY <br />❑ 3. PARTNERSHIP [15. COUNTY AGENCY ❑ 7. FEDERAL 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 PHONE 415 <br />7 -Eleven, Inc. 702-270-7160 <br />416 <br />MAILING OR STREET ADDRESS <br />P.O. Box 711 Attn: Gasoline Acctg. <br />CITY 417 STATE 418 ZIPCODE 419 <br />Dallas TX 75221-0711 <br />TANK OWNER TYPE 2 1. CORPORATION ❑ 2. INDIVIDUAL Lj 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- 3 1 8 9 6 Call 916 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE Z 1. SELF-INSURED [14. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />METHOD(s) ❑ 2. GUARANTEE [-15. LETTER OF CREDIT [:18. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />❑ 3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 422 <br />VI. 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. C]1. FACILITY El2. PROPERTY OWNER ® 3. TANK 423 <br />OWNER <br />VII. APPLICANT SIGNATURE <br />Certification - ce hat lh form n provided herein is true and accurate to the best of my knowledge. <br />SIGNATUR PPLI DATE 424 PHONE 425 <br />702-270-7160 <br />NAME OF APPLICANT (p t) 426 <br />TITLE OF APPLICANT 427 <br />Shane Partridge <br />Gasoline & Environmental Compliance Manager <br />STATE UST FACILITY NUMBER (For local use only) 428 <br />1998 UPGRADE CERTIFICATE NUMBER (For local use only) <br />429 <br />UPI (1/99 revised) Formerly SWRCB Form A <br />