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Now FIED PROGRAM CONSOLIDATED FOr %T;4KS <br /> UNDERGROUND STORAGE TANKS - FACILITY � 6� <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT IM 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br /> (Check one Hem only) [14.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(sameas FACILITY NAME or MA-Doing Business As) 3 FACILITY ID# 1 <br /> 7-Eleven 17334 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE Lj 4.LOCAL GENCY/DISTRICT' <br /> 4501 Pershin Ave, Stockton, 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 ❑7.FEDERAL AGENCY' 402 <br /> TOTAL NUMBEROF 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 4p7 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 STATE 411 ZIP CODE 412 <br /> Dallas TX 75221-0711 <br /> PROPERTY OWNER TYPE 1.CORPORATION 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT U 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY [-17.FEDERAL 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 41a PHONE 415 <br /> 7-Eleven, Inc. 702-270-7160 <br /> 416 <br /> MAILING OR STREET ADDRESS <br /> P.O. Box 711 Attn: Gasoline Acctq. <br /> CITY 417 1 STATE 41e ZIP CODE 419 <br /> Dallas TX 75221-0711 <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL U 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 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) 1 ❑2.GUARANTEE ❑ 5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> - <br /> [0 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. 7 <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY [12. PROPERTY OWNER ®3.TANK 423 <br /> OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certifw on I certify that Ifie rjformation provided herein is true and accurate to the best of my knowledge. <br /> SIGN A U OF APPLI DATE 424 PHONE 425 <br /> 2 0 702-270-7160 <br /> NAME PPLICANT(p t) 426 TITLE FAP APPLICANT 427 <br /> Shane Partridge Gasoline & Environmental Compliance Manager <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NU MBER(For local use only) 429 <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />