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IED PROGRAM CONSOLIDATED FO � -TANKS <br />UNDERGROUND STORAGE TANKS -FACILITY �(,Q g�°l�l� <br />(one page per site) Page _ of <br />TYPE OF ACTION ❑ I. NEW SITE PERMIT [13. RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br />(Check one item only) ❑ 4. AMENDED PERMIT specify change local use only ❑ 8. TANK REMOVED <br />❑ &TEMPORARY SITE CLOSURE 400 <br />I. FACILITY / SITE INFORMATION 1�2 �2 3 Ll �} <br />BUSINESS NAME ($..a as FACILIW NAME or MA- Doing Business As) 3 'FACILITY ID#� � t <br />1 <br />7 -Eleven 19976 FACILITY OWNER TYPE ❑ 4. LOCAL GENCY/DISTRICT" <br />NEAREST CROSS STREET <br />1399 N. Main St, Manteca, CA ® 1. CORPORATION ❑ 5. COUNTY AGENCY' <br />BUSINESS ® 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY" <br />TYPE [12. DISTRIBUTOR ❑ 4. PROCESSOR ❑ 6. OTHER 403 ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 <br />TOTAL NUMBER OF TANKSIs 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 trusdands? which operates the UST (This is the contact person for the tank records.) <br />2 404 F1Yes ® No 405 aos <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 PHONE 408 <br />7 -Eleven, Inc. 702-270-7160 <br />409 <br />MAILING OR STREET ADDRESS <br />P.O. Box 711 Attn: Gasoline Accto. <br />CITY 410 1 STATE 411 ZIP CODE 412 <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 [17. FEDERAL 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 PHONE 416 <br />7 -Eleven, Inc. 702-270-7160 41e <br />MAILING OR STREET ADDRESS <br />P.O. Box 711 Attn: Gasoline Acctq. 419 <br />CITY 417 STATE 41e ZIP CODE <br />Dallas TX 75221-0711 <br />TANK OWNER TYPE 1. CORPORATION ❑ 2. INDIVIDUAL ❑ 4. LOCAL AGENCY / DISTRICT ❑ Q. <br />STATE AGENCY azo <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- 3 1 8 1 9 1 6 I Call 916 322-9669 if uestions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE ® 1. SELF-INSURED ❑ 4. 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: 422 <br />❑ 3. INSURANCE [-16. EXEMPTION ❑ 9. STATE FUND & CD <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate whichaddress should be used for legal notifications and mailing. azo <br />Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY ❑ 2. PROPERTY OW NER ®3. TANK <br />OWNER <br />VII. APPLICANT SIGNATURE <br />Certification I c & that th 'on provided herein is true and accurate to the best of my knowledge. 426 <br />SIGNATUR APPLI DATE 424 PHONE <br />702-270-7160 <br />429 11 TiTI P f1P APPI (CANT 427 <br />NAME OF ATPLICANT 1111ii --p <br />Shane Partridge Gasoline &Environmental Compliance Manager <br />TATE UST FACILITY NUMBER (For local use only) <br />42e 1998 UPGRADE CERTIFICATE NUMBER (Fo WI only) I azs I <br />UPCF (1/99 revised) Formerly SWRCB Form A <br />