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IED PROGRAM CONSOLIDATED FOPft <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT 3.RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE/y <br /> (Check one dem only) ❑4.AMENDED PERMIT specify change legal use only ❑ 8.TANK REMOV 1,r\ryS <br /> ❑6.TEMPORARY SITE CLOSURE `(1V 400 <br /> I. FACILITY/SITE INFORMATION <br /> BU SINESS NAM E(Same as FACaIry NAME or DBA-Doing Business As) 3 FACILITY ID# oI <br /> 1 <br /> 7-Eleven 17334 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> 4501 Pershing Ave, Stockton, CA Z 1. CORPORATION ❑5.COUNTY AGENCY' 7 <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL -16.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 ❑ 3. PARTNERSHIP [17.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 ti�I <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 2 aoa ❑ Yes Z No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> 7-Eleven, Inc. 208-429-8466 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. Box 711 Attn: Gasoline Acctg. <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> Dallas TX 75221-0711 <br /> PROPERTY OWNER TYPE Z 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 415 <br /> 7-Eleven, Inc. 208-429-8466 <br /> MAILING OR STREET ADDRESS 41s <br /> P.O. Box 711 Attn: Gasoline Acctg. <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Dallas TX 75221-0711 <br /> TANK OWNER TYPE Z 1.CORPORATION (12. INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <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 9 6 Call (916) 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED [14.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 /> Z 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. ❑ 1.FACILITY ❑2. PROPERTY OWNER Z 3.TANK 423 <br /> OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification4cthat a infodnation provided herein is true and accurate to the best of my knowledge.SIGNATU NT DATE 424 PHONE 425 <br /> 7 Jl p Z (208)429-8466 <br /> NAME OF PLI ANT(print) <br /> 42s TITLE OF APPLICANT 427 <br /> Bob DeN nno Environmental Manager <br /> STATE UST FACILITY NUMBER(For local use only) 42e 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />