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1 ►J <br /> UNIFIED PROGRAM CONSOLIDATED FORM <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 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID# 1. <br /> 2 1 (Agency Use Only) Z S <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> 7-Eleven 20632 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 4627 Da Vinci Dr. 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 /> Howard N Sweet & C antoninette Sweet-Blankenship (209) 526-0755 <br /> MAILING ADDRESS 409. <br /> P.O. Box 4174 <br /> CITY 410. STATE 411. ZIP CODE 411 <br /> Modesto CA 95352 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1• PHONE 428-2. <br /> 7-Eleven Inc. (916) 463-6776 <br /> MAILING ADDRESS 428-3. <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 428-4.t STATE 428-5. ZIP CODE 428-6. <br /> Dallas TX 75221 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> 7-Eleven Inc. (800) 828-0711 <br /> MAILING ADDRESS 416. <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 417.1 STATE 418. ZIP CODE 419. <br /> Dallas TX 75221 <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- 3 1 $ Q 6 1 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 ❑ 4.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 SIGNATURE DATE 424 PHONE 425• <br /> �.-- <br /> IL/,?,/0 t- (916) 463-6776 <br /> APPLICANT NAME(print) 426 APPLICANT TITLE 427 <br /> Ian Moorhead Environmental Compliance Manager fy <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidoes.org ., <br />