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!NIF PROGRAM CONSOLIDATED Ff `10 <br /> TANKS <br /> A UNDERGROUND STORAGE TANKS - FACILITY <br /> Q� J (one page per site) Page_of_ <br /> TYPEOY 5JON ••El1.NEW SITE PERMIT ❑3.RENEWAL PERMIT [I5.CHANGE OF INFORMATION [ITPERMANENTLY CLOSED SITE <br /> (Check ryij Win onliE ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑B.TEMPORARY SITE CLOSURE <br /> 4p6 <br /> CM T 1. FACILITY lSITE'-INFORMATION <br /> BUSINESSAME a as FACILITY NAME or DBA-Doing Business As) 3 '..FACILITY IM <br /> 7-Elevin 321gi <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4. LOCAL GENCY/DISTRICT` <br /> 4943 S. State Route 99, Stockton, CA ® 1.CORPORATION [15.COUNTY AGENCY` <br /> BUSINESS 1.GAS STATION Ej 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 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 /> 3 469 ❑ Yes ® No 405 4136 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> WEC-99-4 LLC <br /> MAILING OR STREET ADDRESS 409 <br /> 15601 Dallas Parkway, Suite 400 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Dallas TX 75001 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑ 7.FEDERAL 413 <br /> III.TANK OWNERINFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 7-Eleven, Inc. as agent for WEC-99-4 LLC 253-796-7170 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O. Box 711 Attn: Gasoline Acct <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 [17.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HO 44- 1 3 1 1 1 8 9 6 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE Ell.SELF-INSURED ❑4. SURETY BOND ❑7.STATE FUND ❑ 10. LOCALiGOVT MECHANISM <br /> METHOD(s) [12.GUARANTEE ❑ 5.LETTER OF CREDIT [18.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> - <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 ®3.TANK 423 <br /> OWNER <br /> VIL'APPLICANT SIGNATURE <br /> Certification-I c I at the inform Ion pm4ded herein is true and accurate to the best of my knov ge. <br /> SIGNATOR P T 424 PHONE 425 <br /> 253-796-7170 <br /> NAME OF APPLICANT(pd ) 426 TITLE OF APPLICANT 427 <br /> Randy Martin Environmental Manager <br /> STATE UST FACILITY NUMBER IForlocafuss only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local useonly) 429 <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />