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U4 IED PROGRAM CONSOLIDATED FORM* <br /> TA <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_ f <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT 3.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 O_ <br /> ❑6.TEMPORARY SITE CLOSURE \Q\ <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESSNAME(Same as FACILITY NAME or DBA-DoingBusiness As) 3 FACILITY ID# <br /> 7-Eleven 19976 = (� <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT• <br /> 1399 N. Main St, Manteca, CA ® 1.CORPORATION ❑ 5.COUNTY AGENCY' <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL <br /> ❑ 2. INDIVIDUAL [16.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.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 trustlands? which operates the UST(This is the contact person for the tank records.) ql(N <br /> 3 404 F] Yes ® No 405 <br /> 06 <br /> It. PROPERTY OWNER INFORMATION' <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> 7-Eleven, Inc. 208-429-8466 <br /> MAILING OR STREET ADDRESS <br /> P.O. Box 711 Attn: Gasoline Acctg. 409 <br /> CITY 410 STATE 411 <br /> ZIP CODE 412 <br /> Dallas TX 75221-0711 <br /> PROPERTY OWNER TYPE ® i.CORPORATION ❑2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6. STATE AGENCY <br /> ❑ 3. PARTNERSHIP ❑ 5.COUNTY AGENCY [17. FEDERAL 413 <br /> l <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 7-Eleven, Inc. 208-429-8466 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O. Box 711 Attn: Gasoline Acctg. <br /> CITY 417 1 STATE 41e ZIP CODE 419 <br /> Dallas TX 75221-0711 <br /> TANK OWNER TYPE ® 1.CORPORATION 2. INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT El 6.STATE AGENCY 420 <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 LIST 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: <br /> ®3. INSURANCE ❑6. EXEMPTION ❑9. STATE FUND&CD 422 <br /> VI. LEGALNOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which atldress should be used for legal notifications and mailin <br /> Legal notificmessoxorscecetl. ❑ 1. FACILITY ❑2. PROPERTY OWNER ®3.TANK 423 <br /> OWNER <br /> VII. APPLICANT SIGNATURE <br /> C <br /> ertificatione in rmation provided herein is true and accurate to the best of my knowledge. <br /> DATE � I Z � ;r 424 PHONE 42s <br /> (208)429-8466 <br /> NAME Oprint) 4zs TITLE OF APPLICANT4z7 <br /> Bob DeEnvironmental Manager <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local useonly) 42s <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />