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IFIED PROGRAM CONSOLIDATED FO <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 0&CHANCE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6 TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY I SITE INFORMATION <br /> BUSINESS NAME(same as FACIJry NAME«DeA-Doing Business As) 3 FACILITYID# <br /> 1 <br /> 7-Eleven 17334 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT" <br /> 4501 Pershln Ave, SfOCktOn, 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 4o3 ❑ 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 /> 2 404 ❑ Yes ® NO 405 406 <br /> It. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 1 PHONE 408 <br /> 7-Eleven, Inc. 702-270-7160 <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 01.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL 413 <br /> Ill.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 7-Eleven, Inc. 253-796-7170 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O. Box 711 Attn: Gasoline Acct . <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> Dallas TX 75221-0711 <br /> TANK OWNER TYPE 101.CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY azo <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 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 ❑ 10.LOCAL GOvr MECHANISM <br /> METHOD(s) ❑2.GUARANTEE ❑5. LETTER OF CREDIT ❑B.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> ®3.INSURANCE ❑6.EXEMPTION [19.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 /> Certification-I ce fy the 'o vided herein is true and accurate to the best of my knowledge. <br /> SIGNATUR F P AN DATE 424 1 PHONE 425 <br /> 8/14/06 253-796-7170 <br /> NAME OF PLICANT(print) 426 TITLE OF APPLICANT d21 <br /> Randy Martin Gasoline & Environmental Compliance Manager <br /> STATE UST FACILITY NUMBER(Forlocal use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />