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6_1 6-13 IV) <br /> Mh :V <br /> FIED PROGRAM CONSOLIDATED FOR <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFOXX. �TION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 41x1_ <br /> (Check one item only) ❑ 3.RENEWAL PERMIT 6.TEMPORARY FACILITY CLOSURE <br /> ❑ ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# <br /> 2 (Agency Use Only <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> 7-Eleven 19976 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1399 N. Main Manteca <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME am. PHONE 408. <br /> 7-Eleven Inc. (916) 463-6776 <br /> MAILING ADDRESS 409. <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 410.t STATE 411• ZIP CODE 412. <br /> Dallas TX 75221 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> 7-Eleven Inc. (916) 463-6776 <br /> MAILING ADDRESS 428-3• <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 428-4 STATE 428-5• ZIP CODE 428-6. <br /> Dallas TX 75221 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> 7-Eleven Inc. (800) 828-0711 <br /> MAILING ADDRESS 416• <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Dallas TX 75221 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44 3 1 $ 9 6 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 423. <br /> p g g ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required far Public Agencies Only) s. 406. <br /> e <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with legal requirements. <br /> APPLICANJSIGNATURE DATE 424 PHONE a s. <br /> "T-- � J (916) 463-6776 <br /> APPLICANT NAME(print) 426• APPLICANT TITLE 427 <br /> Ian Moorhead Environmental Compliance Manager <br /> % <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org �' <br />