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w /y <br /> t.r <br /> UIED PROGRAM CONSOLIDATED FO .lA L "t <br /> UNDERGROUND STORAGE TANKS <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> `(one form per facility) <br /> Page of <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) <br /> ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID# <br /> 3 (AGENCY Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA—Doing Business As) 3 <br /> 7-ELEVEN INC#35355 <br /> BUSINESS SITE ADDRESS 103 CITY <br /> 3202 W HAMMER LANE STOCKTON <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is facility on Indian Reservation or Trust <br /> lands? <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER <br /> Yes No <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 402 PHONE <br /> 7-ELEVEN INC 800-828-0711 <br /> MAILING ADDRESS 404 <br /> P.O. BOX 711 ATTN: ENVIRONMENTAL DEPARTMENT <br /> CITY 405 STATE 406 ZIP CODE <br /> DALLAS TX 75221 <br /> III.TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE <br /> 7-ELEVEN INC 800-828-0711 <br /> MAILING ADDRESS 428-3 <br /> P.O. BOX 711 ATTEN: ENVIRONMENTAL DEPARTMENT <br /> CITY 428-4 STATE 428-5 ZIP CODE <br /> DALLAS TX 75221 <br /> IV.TANK OWNER INFORMATION <br /> TANK OWNER NAME 408 PHONE <br /> 7-ELEVEN INC 800-828-0711 <br /> MAILING OR STREET ADDRESS 410 <br /> P.O. BOX 711 ATTEN: ENVIRONMENTAL DEPARTMENT <br /> CITY 411 STATE 412 ZI CODE <br /> DALLAS TX 75221 <br /> OWNER TYPE D 4. LOCAL AGENCY/DISTRICT 5. COUNTY AGENCY Li 6. STATE AGENCY <br /> ❑ 7. FEDERAL AGENCY ® 8. NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 0 3 1 1819161 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 415 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1. FACILITY OWNER ❑ 4. TANK OPERATOR 41 <br /> 3. TANK OWNER 3. FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,08 OFFICE(Required For Public Agencies Only) 406 <br /> VII. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the Information provided herein Is true,accurate and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 417 PHONE <br /> 10/27/11 858-694-0433 <br /> APPLICANT NAME(print) 419 APPLICANT TITLE 420 <br /> BREANNA HARMON REGIONAL ENVTL COMPLIANCE SPECIALIST <br /> UPCF UST-A Rev.(12/2007) <br /> 7-ELEVEN INC#35355, Belshire Environmental Services <br />