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Ad f <br /> D <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK i <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION { <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1 NEW PERMIT [35 CHANGE OF INFORMATION El '7 PERMANENT FACILITY CLOSURE 900 <br /> (rheck0"item only) 3 RENEWAL PERMIT ❑ 6 TEMPORARY FACILITY CLOSURE ❑ 9 TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF UST.AT FACILITY 40a FACILI T Y ID 0 <br /> �-- (Agency Ure Only) <br /> BUSINESS NAME(Same as FacilityName or DBA-Doing Businerr Ar) 1 <br /> CRLLC #2705446 _ 104 f j <br /> BUSINESS SITE ADDRESS 107 CITY <br /> 1403 Count Club Blvd Stockton, CA 95204 iIE <br /> 405 <br /> FACILITY TYPE ® 1 MOTOR VEHICLE FUELING [32 FUEL DISTRIBUTION 901 Is the facility located on Indian Reservation or <br /> 3.FARM ❑ 4.PROCESSOR 6.OTHER Trust lands? ❑ 1 Yes ❑ 2 No <br /> 408 <br /> PROPERTY OWNER NAME 407 PHONE <br /> Convenience Retailers, LLC (925)884-0800409 <br /> ` <br /> MAILING ADDRESS ^� <br /> P.O. Box 3290 _ _ <br /> CITY 410 STATE 11 ZIP CODE 412 <br /> San Ramon CA 94583 <br /> �r't'4T"-,.-- <br /> TANK OPERATOR NAME 42a1 PHONE 428-2 < <br /> Convenience Retailers, LLC _ (925)884-0800_ <br /> MAILING ADDRESS azs-z <br /> i <br /> P.O. Box 3290 <br /> CITY <br /> --- _ - 4284 STATE 438 s ZIP CODE 4ae s <br /> San Ramon CA 94583 <br /> �; 1 � 2 -!' ,s •c � rY� " f n an "4 <br /> YS „} k_•! '�y\P. .Y. 7,�. ...Ili_.• }�R.t F. <br /> TANK OWNER NAME ala PHONE 415 <br /> Convenience Retailers, LLC (925)884-0800 <br /> —___— <br /> MAILING ADDRESS _ <br /> P.O. Box 3290 <br /> CITY a17 STATE 411 ZIP CODE 419 <br /> San Ramon _ �A _ 94583 <br /> OWNER TYPE: ❑ 4 LOCAL AGENCYIDISTRICT ❑ 5 COUNTY AGENCY ❑ 6 STATE AGENCY 420 ' <br /> ❑ 7 FEDERALAGENCY S NON-GOVERNMENT <br /> TY(TK)HQ 44 Call the State Board of Equalization Fuel Tax Division if there ate questions 421 <br /> _ t <br /> t � j <br /> V. <br /> v.. <br /> 921 <br /> Issue permit and send legal notifications and mailings to: ® t FACILITY OWNER F] 4 TANK OPERATOR <br /> ❑ 3 TANK OWNER ❑ 5 FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406 i <br /> VIL APPLICANT SIGNATURE _ <br /> CER FIC TI Icer that the' mation rovided herein is hu accurate and in full com liance with to sl requirements. <br /> AP ICA S TUR DATE 424 1 PHONE 425 <br /> _ —p 925 884-0800 <br /> AW-WANT NAMEKrint) 426 APPLICANT TITLE 427 <br /> Chuck J. So ich Mana er of Compliance & Maintenance <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidoes.org <br /> i <br /> I <br />