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IED PROGRAM CONSOLIDATED FOO <br />bI TANKS <br />ti <br />UNDERGROUND STORAGE TANKS -FACILITY Qi) �rPage <br />5 <br />(one page per site) _ of <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br />(Check one item only) <br />❑ 4. AMENDED PERMIT specify change local use only El 8. TANK REMOVED ❑ 6.TEMPORARY SITE CLOSURE 400 <br />1. FACILITY I SITE INFORMATION2f� 2 5 <br />BUSINESS NAME(Same as FACILITY NAME or DBA- Doing Business As) 3 FACILITY ID# 1 <br />7-Eleven 17647 L <br />FACILITY OWNER TYP❑ E 4. LOCAL GENCY/DISTRIC <br />NEAREST CROSS STREET 401 T <br />' <br />1048 ST Yosemite, Manteca, CA ® 1. CORPORATION ❑ 5. COUNTY AGENCY- <br />BUW. SINESS ® 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY' <br />TYPE ❑ 2. DISTRIBUTOR [14. PROCESSOR ❑ 6. OTHER 403 ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 <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 />REMAINING AT SITE trustlands7 which operates the UST (This is the contact person for the tank records.) <br />406 <br />2 404 E]Yes ® No 405 <br />It. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 PHONE 406 <br />702-270-7160 <br />7-Eleven, Ina 4g9 <br />MAILING OR STREET ADDRESS <br />P.O. Box 711 Attn: Gasoline Acctg. 410411 ZIP CODE 412 <br />CITY STATE <br />Dallas TX 75221-0711 <br />PROPERTY OWNER TYPE 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 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 a1s <br />702-270-7160 <br />7-Eleven, Inc. 416 <br />MAILING OR STREET Ah <br />P.O. Box 711 AttnAcct 419 <br />CITYOf STATE 416 ZIP CODE <br />DallasTX 75221-0711 <br />TANK OWNER TYPEORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY /DISTRICT ❑ 6. STATE AGENCY 420 <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY [17. FEDERAL AGENCY <br />ARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HO 44- 9 6 <br />Call 916 322-9669 if questions arise IMECHANISM <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE ® URED [14. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL!GOVTMETHOD(s) ❑TEE ❑ 5. LETTER OF CREDIT ❑8. STATE FUND & CFO LETTER ❑ 99. OTHE <br />❑ CE ❑ 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 />Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK 423 <br />OWNER <br />VIL APPLICANT SIGNATURE <br />Certification -f c%ifgthat they06Wff Vn provided herein is true and accurate to the Dee, v; I I I mw..Ga <br />t 425 I <br />Shane Partridge <br />STATE UST FACILE <br />UPCF (1/99 revised) <br />702-270-7160 <br />Gasoline & Environmental Compliance Manager <br />(For local use only) 426 1998 UPGRADE CERTIFICATE NUMBER (For local use only) <br />Formerly SWRCB Form A <br />