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I IED PROGRAM CONSOLIDATED FO O I y T <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(one page per site) Page _ of <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ID 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 />1. FACILITY I SITE INFORMATION p PL D Z 3 0-7 <br />BUSINESS NAME (Sameas FACILINNAMEor DBA- Doing Business As) 3 FACILITY ID#.. V 6/ L1 I 1 <br />7 -Eleven 20632 <br />NEAREST CROSS STREET ao1 FACILITY OWNER TYPE ❑ 4. LOCAL unlluviY AGENCY' <br />4627 <br />4627 DaVinci Dr., StOCktOn, CA ® CORPORATION ❑ 5. COUNTY AGENCY' <br />BUSINESS ® 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 trustands? which operates the UST (This is the contact person for the tank records.) <br />406 <br />2 aob ❑Yes ®No 405 <br />II. PROPERTY OWNER INFORMATION <br />aoe <br />PROPERTY OWNER NAME 407 PHONE <br />Howard N Sweet & C Antoninette Sweet-Ednnkpnshin <br />409MAILING OR STREET ADDRESS <br />P.O. Box 4174 a10 STATE 411 ZIP CODE 412 <br />CITY <br />ModestoCA 95352 <br />PROPERTY OWNER TYPE 1. CORPORATION 2. INDIVIDUAL 4. LOCAL AGENCY /DISTRICT ❑ 6. STATE AGENCY <br />[13. PARTNERSHIP ❑ 5. COUNTY AGENCY [17. FEDERAL 413 <br />111, TANK OWNER INFORMATION <br />TANK OWNER NAME 414 PHONE 415 <br />7 -Eleven, Inc. 702-270-7160 46 <br />MAILING OR STREET ADDRESS <br />P.O. Box 711 Attn: Gasoline Acctg 419 <br />CITY 417 1 STATE 41e 1 ZIP CODE <br />Dallas TX 75221-0711 <br />TANK OWNER TYPE 1. CORPORATION 3PRDISTRICT T ERSHIP ❑ 5. COUNTY AG NCYO 6. FEDERAL AGENCY 420 <br />SIAIE AGENCY <br />❑.A <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HO 44- 3 1 8 9 6 <br />Call 916 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE ® 1. SELF-INSURED 1-14. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />METHOD(s) ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT [18. STATE FUND & CFO LETTER ❑ 99. OTHER: 422 <br />❑ 3. INSURANCE ❑ 6. EXEMPTION [-19. 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 C1 2. PROPERTY OWNER ®3. TANK 423 <br />OWNER <br />VII. APPLICANT SIGNATURE <br />UPCF (1/99 revised) Formerly SWRCB Form A <br />