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IED PROGRAM CONSOLIDATED FOFqF <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(one page per site) Page <br />TANKS <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br />(Check one item only) ❑ 4. AMENDED PERMIT specify change local use only ❑ 8. TANK REMOVED <br />❑ 63EMPORARY SITE CLOSURE 400 <br />I. FACILITY / SITE INFORMATION <br />BUSINESS NAME (Same as FACILITY NAME or DBA- Doing Business As) 3 1 FACILITYFZ1 <br />01I0:::ILITY �[E]14. <br />7 -Eleven 19976 <br />NEAREST CROSS STREET ao1 OWNER TYPE LOCAL GENCY/DISTRICT* <br />1399 N. Main St, Manteca, CA 1. CORPORATION ❑ 5. COUNTY AGENCY*BUSINESS <br />® 1. GAS STATION ❑ 3. FARM ❑5. COMMERCIAL 2. INDIVIDUAL ❑ 6. STATE AGENCY* <br />TYPE ❑ 2. DISTRIBUTOR ❑ 4. PROCESSOR [16. OTHER 403 ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY* 402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />If owner of UST is a public agency: name of supervisor of division, section or office <br />REMAINING AT SITE <br />trustlands? <br />which operates the UST (This is the contact person for the tank records.) <br />2 404 <br />❑ Yes ® No 405 <br />406 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 406 <br />7 -Eleven, Inc. 1 <br />702-270-7160 <br />MAILING OR STREET ADDRESS 409 <br />P.O. Box 711 Attn: Gasoline Acctg. <br />CITY 410 <br />STATE 411 <br />ZIP CODE 412 <br />Dallas <br />TX 1 <br />75221-0711 <br />PROPERTY OWNER TYPE ®1. CORPORATION ❑ 2. 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. 702-270-7160 <br />416 <br />MAILING OR STREET ADDRESS <br />P.O. Box 711 Attn: Gasoline Acctg. <br />CITY 417 <br />STATE 415 <br />ZIP CODE 419 <br />Dallas I <br />TX <br />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 HQ 44- 1 3 1 1 8 19 16 1 Call 916 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE 17-11. SELF-INSURED ❑ 4. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />METHOD(s) ❑ 2. GUARANTEE 1715. LETTER OF CREDIT [18. STATE FUND & CFO LETTER ❑ 99. OTHER: <br />® 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 [12. PROPERTY OWNER ® 3. TANK 423 <br />OWNER <br />VII. APPLICANT SIGNATURE <br />Certif ati n - I certify th t information provided herein is true and accurate to the best of my knowledge. <br />SIGN <br />RE OF APP CA T <br />DATE ata <br />% /Z 6 b:(o <br />PHONE azs <br />702-270-7160 <br />NAME OF APPLICANT rint) 426 <br />TITLE OF APPLICANT 427 <br />Shane Partridge <br />Gasoline & Environmental Compliance Manager <br />STATE UST FACILITY NUMBER (For local use only) 428 <br />1998 UPGRADE CERTIFICATE NUMBER (For local use only) a29 <br />UPCF (1/99 revised) Formerly SWRCB Form A <br />