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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION— FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ I NEW PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6 TEMPORARY FACILIIY CLOSURE ❑ 9, TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER_OF USTs AT FACILITY 404 FACILITY ID# 1 _ 1 _ 1 <br /> ¢ I I I <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3 <br /> CRLLC #2705448 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 3202 W. Hammer Lane Stockton, CA 95209 <br /> FACILITY TYPE Z 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 Z 2 No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME PHONE 408 <br /> 407 <br /> Convenience Retailers, LLC (925) 884-0800 <br /> MAILING ADDRESS 409 <br /> P.O. Box 3290 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> San Ramon CA 194583 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE. 428-2 <br /> Convenience Retailers, LLC (925) 884-0800 <br /> MAILING ADDRESS 428-3 <br /> P.O. Box 3290 <br /> CITY 428.4 STATE 428-5 ZIP CODE 428-6 <br /> San Ramon CA 94583 <br /> IV TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> Convenience Retailers, LLC (925) 884-0800 <br /> MAILING ADDRESS 416 <br /> P.O. Box 3290 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> San Ramon CA 94583 <br /> OWNER IYPE: ❑ 4,LOCAL AGENCY/DISTRICT ❑ 5 COUNTY AGENCY ❑ 6 STATE AGENCY 420 <br /> ❑ 7 FEDERAL AGENCY "'K8 NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- C C-" Lj, I 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: Z I FACILITY OWNER ❑ 4 TANK OPERATOR 423 <br /> ❑ 3 TANK OWNER ❑ 5 FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required fop Public Agencies Only) 406 <br /> VIL APPLICANT SIGNATURE <br /> CE IFICA O . I c if that thein ation provided herein is true,accurate,and in full compliance with le al re uirements. <br /> LIC NT NAT U DATE 424 PHONE 425 <br /> 925) 884-0800 <br /> ICANT N print) 426 APPLICANT TITLE I 427 <br /> Chuck J. oftich Manager of Compliance & Maintenance <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />