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0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM `Ig <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 aoo <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> TOTAL NUMBER OF LISTS AT FACILITY 4oaFACILITY IDN � t <br /> 4 (Agency Use Only) <br /> BUSINESS NAME(Same as FacilityName or DBA—Doing Business As) <br /> Circle K/76#2705446 <br /> BUSINESS SITE ADDRESS 103 CITY 104. <br /> 1403 Country Club Blvd. Stockton <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 /> PROPERTY OWNER NAME 407 PHONE Jog <br /> Convenience Retailers LLC. 281 293-5101 <br /> MAILING ADDRESS 409 <br /> 600 N. Dairy Ashford, Suite TA 1138B <br /> CITE` 419 STATE 411 I ZIP CODE ail. <br /> Houston ITX 177079 <br /> M.: TAMC JPERAT4R I E l # I411F <br /> TANK OPERATOR NAME a'-E 1 PHONE 428'2 <br /> Convenience Retailers LLC. 1 (281) 293-5101 <br /> MAILING ADDRESS 429.3, <br /> 600 N. Dairy Ashford, Suite TA 1138B <br /> CITY 42" STATE d2-9-3 ZIP CODE 428-6, <br /> Houston 7 + TX 77079 <br /> TANK OWNER NAME +la PHONE 415 <br /> Convenience Retailers LLC. (281) 293-5101 <br /> MAILING ADDRESS alb, <br /> 600 N. Dairy Ashford, Suite TA 1138E <br /> at <br /> CITY 7 STATE acs ZIP CODE ate, <br /> Houston JTX 177019 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® S.NON-GOVERNMENT 1 <br /> 1')I0 UST- 4TOI [IE 1' E A! +CMB <br /> TY(TK)HQ 44- 1 21 5 17 1 91 9 1 9 �]/� Call the State Board <br /> of Equalization Fuel Tax Division,if there are questions. 421 <br /> 11V <br /> PMT <br /> Issue permit and send legal notifications and mailings to: ❑ I.FACILITY OWNER ❑ 4.TANK OPERATOR 423. <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> f SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Onty) 406, <br /> i <br /> ,r <br /> VIL APPLICANT SidA'T» <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424 1 PHONE 425, <br /> 7/10/2008 970)692-4257 <br /> APPLICANT NAME(print) 426 APPLICANT TITLE 427 <br /> Tim Wind Project Manager/Agent for Owner <br /> UPCF UST-A Rev.(12/2007)-U2 www.uuidocs.org <br />