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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> E:: <br /> OPERATING PERMIT APPLICATION -FACILITY INFORMATION <br /> (One form per facility) <br /> 400. <br /> TYPE OF ACTION El 1.NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# T TT_ _ // / t <br /> (Agency Use Only) l"' ``f <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3' <br /> CRLLC #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 /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> Convenience Retailers, LLC 925 884-0800 <br /> MAILING ADDRESS 409. <br /> PO Box 3290 <br /> CITY 410 STATE 411. ZIP CODE 412. <br /> San Ramon CA 94583 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428-1 <br /> Convenience Retailers, LLC (925) 884-0800 <br /> MAILING ADDRESS 428-3. <br /> PO Box 3290 <br /> CITY 4284. 1 STATE azs•s. ZIP CODE 428-6. <br /> San Ramon CA 194583 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Convenience Retailers, LLC (925) 884-0800 <br /> MAILING ADDRESS 416. <br /> PO Box 3290 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> San Ramon CA 94583 <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- = Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER El4.TANK OPERATOR 423. <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 compliance with legal requirements. <br /> APPLICANT SIGNATUREDATE 424. PHONE azs. <br /> 03 (925)884-0800 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Armen Mkrtychian California Compliance Manager <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />