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IFIED PROGRAM CONSOLIDATED F* Cr <br /> UNDERGROUND STORAGE TANK11 <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATIONam` 59 <br /> (One form p�r�fz <br /> TYPE OF ACTION ❑ 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one it(m only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY FACILITY ID# _ <br /> 4 (Agency Use Only <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3. <br /> Convenience Retailers, LLC #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? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME aoz PHONE 408• <br /> Convenience Retailers, LLC (714) 428-6572 <br /> MAILING ADDRESS 409. <br /> 600 North Dairy Ashford <br /> CITY 410. 1 STATE all. ZIP CODE 412. <br /> Houston TX 77079 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2 <br /> Convenience Retailers, LLC (209) 943-2082 <br /> MAILING ADDRESS 428.3 <br /> 1403 COUNTRY CLUB BLVD <br /> CITY 428-4 7STATE 428-5 ZIP CODE 428-6 <br /> STOCKTON ICA 95204 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME ata. PHONE 415. <br /> Convenience Retailers, LLC Attn: Licenses & Permits (281) 293-1684 <br /> MAILING ADDRESS 416. <br /> 600 North Dairy Ashford <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> HOUSTON TX 77079 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1014161315141 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue ermit and send legal notifications and mailings to: 423 <br /> p g g ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR 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 com liance with legal requirements. <br /> APPLICANT SIGNATURE DATE 424. PHONE 42 i. <br /> A644" A20k 8/26/2008 (714) 428-6572 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 4 <br /> Stephen Boyd HSE Specialist <br /> UPCF UST-A Rev.(1212007) <br /> I <br />