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� I <br /> i <br /> 1 <br /> Po <br /> UNIFIED PROGRAM CONSOLIDATED]FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> 1 <br /> (One form per facility) <br /> TYPE OF ACIION ❑ 1 NEW PERMIT ® 5 CHANGE OF INFORMATION ❑ 1 PERMANENT FACILITY CLOSURE 600 <br /> ((.'heck one item only) ❑ 3 RENEWAL PERMIT ❑ 6 TEMPORARY FACILITY CLOSURE ❑ 9 TRANSFER PERMIT <br /> I. FACILITY_ INFORMATION _ <br /> TOTAL NUMBER OF USTs AT FACILITY 4oa <br /> FACTLIT (ID# <br /> {Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business Ar) 3 <br /> CRLLC#2705447 <br /> BUSINESS SITE ADDRESS �— —�-- 103 CITY 104 <br /> 1469 E. Hammer Lane Stockton, CA 95210 <br /> 405 <br /> FACILITY TYPE ® 1 MOTOR VEHICLE FUELING [12 FUEL DISTRIBUI ION 403 is the facility located on Indian Reservation or <br /> Trust lands; ❑ I Yes ® 2 No i <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.0THEIR <br /> y�_ * i <br /> Ni�rR <br /> :7 — <br /> PROPERTY OWNER NAME 407 PHONE aos <br /> Convenience Retailers, LLC 925 884-0800 I <br /> MAILING ADDRESS —��--^ y-- 409 <br /> P.O. Box 3290 _ _ <br /> CITY -- 410 STATE 411 ZIP CODE alz <br /> San Ramon CA <br /> 94583 <br /> 77 <br /> MW <br /> TIS <br /> TANK OPERATOR NAME 42S 1 PHONE 428-2 <br /> (925)884-0800 <br /> Convenience Retailers, LLC _ _ I <br /> a2s 3 <br /> MAILING ADDRESS <br /> 1 <br /> P.O. Box 3290` -- <br /> CITY —_-- 429.4 STATE 439 5 ZIP CODE az9 6 <br /> San Ramon CA 94583 <br /> TANK OWNER NAME ala PHONE 415 <br /> Convenience Retailers, LLC (925)884-0800 <br /> 416 <br /> MAILING ADDRESS <br /> P.O. Box 3290 <br /> CITY �— i—_ 417 STATE 419 ZIP CODE 419 t <br /> San Ramon _ __ CA 94583 <br /> OWNER TYPE: [34 LOCAL AGENCY/DISTRICT ❑ 5 COUNTY AGENCY ❑ 6 STATE AGENCY 420 <br /> ❑ 7 FEDERAL AGENCY ❑ 8 NON-GOVERNMENT7777 <br /> 1 <br /> T <br /> TY(TK)HQ 44- ® L( 5 Call the State Board of Equalization,Fuel I ax Division if there are questions <br /> ILII�� FN A TItflN <br /> ..,- -- 423 <br /> Issue permit and send legal notifications and mailings to. ® 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) 606 <br /> i <br /> i <br /> VII.APPLICANT SIGNATURE <br /> CE IC N: Leftfy that the bftmation provided herein is taus accurate,and in full compliance with legal requirements. <br /> ;c, <br /> C NAT E DATE 424 PHONE 425 <br /> —p 925 884-0800 <br /> 426 APPLICANT TITLEank J. oftich Manager of Compliance & Maintenance <br /> l <br /> 1 <br /> UPCF USI-A Rev.(1212007)-1/2 www.unidoes.org y <br /> t <br />