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4IED PROGRAM CONSOLIDATED FOR11 <br /> 4SITE <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT 3.RENEWAL PERMIT [I5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSEDm ❑(Check one teonly) 4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6 TEMPORARY SITE CLOSURE 400 <br /> L FACILITY/SITE INFORMATION I �` <br /> ........... <br /> BUSINESS NAME(Same as FAcwTY eAMEor OeA-oom9 Business Au a FACILITY ID# <br /> 7-Eleven 20632 yn�a, <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE r Ll 4.LOCAL GENCY/DISTRICT• 1" <br /> 4627 DaVinci Dr., Stockton, CA ® 1.CORPORATION [15.COUNTY AGENCY- V <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY' 1��I <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR[16. OTHER 403 ❑ 3. PARTNERSHIP ❑7. FEDERAL AGENCY' 402 C) <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.) <br /> 2 404 E] Yes ® No 405 406 <br /> If. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> Howard N Sweet&C Antoninette Sweet-Blankenship (209) 526-0755 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. Box 4174 <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> Modesto CA 95352 <br /> PROPERTY OWNER TYPE ❑ 1.CORPORATION ❑2.INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑ 6. STATE AGENCY <br /> ❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY ❑ 7. FEDERAL 413 <br /> III.TANK OWNERINFORMATION <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 STATE 418 ZIP CODE 419 <br /> Dallas TX 75221-0711 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑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 1 8 9 6 Call (916) 322-9669 if questions arise 421 <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [110. 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. 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 ill 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 /> Certification-I certify th t t information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF A A DATE 424 PHONE 425 <br /> Z J y (208)429-8466 <br /> NAME OF APPLI ANT(print) 426 TITLE OF APPLICANT 427 <br /> Bob DeNinno Environmental Manager <br /> STATE UST FACILITY NUMBER(Forlocal usecnly) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />