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ins�'..(��-• <br /> f <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1 NEW PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENT FACILITY CLOSURE 400 <br /> (Check one lretn only) ❑ 3 RENEWAL PERMIT ❑ 6 TEMPORARY FACILIIY CLOSURE ❑ 9 TRANSFER PERMIT _ <br /> I� ]EACIIrITY INFO TION <br /> TOTAL NUMBER OF USTs AT FACILITY 4°4 FACILIYY ID# <br /> (Agency Use Only) i <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business Ar) <br /> CRLLC#2705448 <br /> BUSINESS SITE ADDRESS - 103 CITY loa <br /> 3202 W. Hammer Lane _ _ Stockton, CA 95209 _ <br /> FACILITY TYPE ® 1 MOTOR VEHICLE FUELING [12 FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or aos t <br /> 3.FARM ❑ 4.PROCESSOR C] 6.OTHER crust lands? ❑ i Yes ® 2 No <br /> II. <br /> .0 [ERINI{O `M TIt}N <br /> 40$ <br /> PROPERTY OWNER NAME - 407 PHONE <br /> Convenience Retailers, LLC (925)884-0800 } <br /> MAILING ADDRESS -- 409 <br /> P.O. Box 3290 <br /> CITY ^� 410 STATE 411 ZIP CODE alz j <br /> San Ramon CA 94583 <br /> ssspi s � RSA z 're *. <br /> TANK OPERATOR NAME 4251 PHONE 428-2 ! <br /> Convenience Retailers, LLC (925)884-0800 <br /> MAILING ADDRESS 428-3 <br /> P.O. Box 3290 _ _ I <br /> azs s <br /> CITY - 42sn STATE 428-5 ZIP CODE i <br /> San Ramon 194583 <br /> TANK OWNER NAME 414 j PHONE au <br /> Convenience Retailers LLC (925) 884-0800_ _ <br /> MAILING ADDRESS -�—�_ 416 1 <br /> P.O. Box 3290 <br /> CITY —� 417 STATE 419 ZIP CODE 419 <br /> San RamonCA 94_5_83 I <br /> OWNER TYPE: � ❑ 4 LOCALAGENCY/DISTR[CT _ ❑ S COUNTY AGENCY ❑ 6 STATE AGENCY <br /> 420 <br /> ❑ 7 FEDERAL AGENCY ❑ 8 NON-GOVERNMENT <br /> ENTrS <br /> 4/ TRJ^ ii` A � <br /> TY(TK)HQ 44- s Call the State Board of Equalization,Fuel Tax Division if there are questions 421 I <br /> ... .. •.. ..: '. ... i.. 423 ( <br /> Issue permit and send legal notifications and mailings to. ® 1 FACILITY OWNER ❑ 4 IANK OPERATOR I <br /> ❑ 3 IANK OWNER ❑ 5 FACILITY OPERATOR !I f <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required jot Public Agencies Only) 406 <br /> VII. APPLICAN.T SIGNATURE _ <br /> CER11FICAY10W I rpAIfy1hat the in tion provided herein is true accurate and in full compliance with legal requirements. <br /> Ll ATU DATE aaa PHONE aas <br /> — 925)884-0800 _ <br /> ICANT N print) 426 APPLICANT TITLE 427 <br /> Chuck J. ofti( Manager of Comliance & Maintenance <br /> f <br /> 1 <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br /> i <br />