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PROGRAM CONSOLIDATED FOR1040 TF <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT E 3.RENEWAL PERMIT ❑5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SIE 1 b2 <br /> (Check one item only) [14.AMENDED PERMIT specify change local use only ❑ 8.TANK RweVED I f) <br /> l _ l <br /> ❑63EMPORARY SITE CLOSURE 40 <br /> 1. FACILITY I SITE INFORMATION <br /> BUSINESS NAME(same as FACILITY NAME or DBA Doing Business As) 3 FACILITY ID# <br /> 7-Eleven 32190 ✓C <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT <br /> 4943 S. State Route 99, Stockton, CA E 1.CORPORATION [15.COUNTY AGENCY' <br /> BUSINESS E 1.GAS STATION ❑3.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP ❑7.FEDERAL AGENCY' 402 <br /> TOTAL NUMBER OF TANKS I5 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 /> 3 404 ❑ Yes E No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 406 <br /> WEC-99-4 LLC <br /> MAILING OR STREET ADDRESS 409 <br /> 15601 Dallas Parkway, Suite 400 <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> Dallas TX 75001 <br /> PROPERTY OWNER TYPE E 1.CORPORATION [12. INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6. STATE AGENCY <br /> ❑ 3. PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7. FEDERAL 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 7-Eleven, Inc. as agent for WEC-99-4 LLC 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 E 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- 1 3 1 1 8 9 16 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 ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) [12.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99. OTHER: <br /> E 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 E 3.TANK 423 <br /> OWNER <br /> VII APPLICANT SIGNATURE <br /> Certification-I ce that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE F P T - DATE 424 PHONE 425 <br /> 12 u L (208)429-8466 <br /> NAME OF PLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Bob DeNi no Environmental Manager <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local useonly) 429 <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />