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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION— FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ l NEW PERMIT ® 5 CHANGE OF INFORMATION ❑ 7 PERMANENT FACILITY CLOSURE 400 <br /> (Check one item only) ❑ 3,RENEWAL PERMIT ❑ 6 IEMPORARY FACILITY CLOSURE ❑ 9 TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER QF JJSTs AT FACILITY 404 FACILITY ID# _ _ 175- <br /> 1 <br /> tr (Agency Use Only) 1 Y <br /> BUSINESS NAME(Same as Facility Name or DBA—Doing Business As) 3 <br /> CRLLC #2705447 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 1469 E. Hammer Lane Stockton, CA 95210 <br /> FACILITY TYPE ® 1 MOTOR VEHICLE FUELING ❑ 2 FUEL DISTRIBUTION 407 Is the facility located on Indian Reservation or 405 <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1 Yes Z 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 /> P.O. Box 3290 <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> San Ramon CA 94583 <br /> IIL TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428.2 <br /> Convenience Retailers, LLC (925) 884-0800 <br /> MAILING ADDRESS 428.3 <br /> P.O. Box 3290 <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> San Ramon CA 94583 <br /> IV TANK OWNER INFORMATION' <br /> TANK OWNER NAME <br /> 41a PHONE 415 <br /> Convenience Retailers, LLC (925) 884-0800 <br /> MAILING ADDRESS 416 <br /> P.O. Box 3290 <br /> CITY 417 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 HOLDEN INFORMATION <br /> . 427.. <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) 406 <br /> VII. APPLICANT SIGNATURE <br /> CE IC N: Ltetnify that the i rmation provided herein is true accurate,and in full compliance with legal requirements. <br /> LIC NAT RE DATE 424 PHONE 425 <br /> -C2 (925) 884-0800 <br /> 114�CAIN";p�rint) 426 APPLICANT TITLE 427 <br /> Chuck J. Softich Manager of Compliance & Maintenance <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />