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U `IED PROGRAM CONSOLIDATED FOR TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_' 01 <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT 3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE I a L <br /> (Check one item only) 4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> L FACILITY/SITE INFORMATION U 1` <br /> 4 BUSINESS NAME(same as FACILITY IVAMEor DBA Doing Business As) 3 FACILITY ID# <br /> 7-Eleven 17647 I Y OWNER TYPE n D ro <br /> NEAREST CROSS STREET ao1 FACILIT ❑4. LOCAL GENCY/DISTRIC <br /> 1048 W. Yosemite, Manteca, CA ® 1.CORPORATION ❑ 5.COUNTY AGENCY' <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2. INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. 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 <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 2 404 ❑ Yes ® 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 STATE 411 ZIP CODE 412 <br /> Dallas TX 75221-0711 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2. INDIVIDUAL [14.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑ 3. PARTNERSHIP ❑ 5.COUNTY AGENCY ❑7. FEDERAL 413 <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 7-Eleven, Inc. 208-429-8466 <br /> 41s <br /> MAILING OR STREET ADDRESS <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 [:16.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 [15. 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 will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK 423 <br /> OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certificatio*atthe p provided herein is true and accurate to the best of my knowledge. <br /> SIGNATDATE 424 PHONE 425 <br /> 7 L 0�� (208)429-8466 <br /> NAMEO426 TITLE OF APPLICANT 427 <br /> Bob DeEnvironmental Manager <br /> STATE UST FACILITY NUMBER(For local use only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />