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6 0 <br /> UNIFIED PROGRAM CONSOLIDATED FORM j <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION- FACILITY INFO ATION t° <br /> (One form per facility) g o2 <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 /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID# _ _ _ 1. <br /> 4 (Agency Use Only) J L- <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> CRLLC/76 #5447 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1469 E Hammer Lane 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 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 /> 7180 Koll Center Pkwy <br /> CITY 410 STATE 411. ZIP CODE 412. <br /> Pleasanton CA 94566 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME azs-1 PHONE 428-2. <br /> Convenience Retailers, LLC (925) 884-0800 <br /> MAILING ADDRESS 428-3. <br /> 7180 KoliCenter Pkwy <br /> CITY 428-4. 1 STATE 428-5. ZIP CODE 428-6. <br /> Pleasanton CA 94566 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> Convenience Retailers, LLC (925) 884-0800 <br /> MAILING ADDRESS 416. <br /> 7180 Koll Center Pkwy <br /> CITY 417. STATE 418, ZIP CODE 419. <br /> Pleasanton CA 94566 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 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- 0 4 6 3 5 4 Call the State Board of Equalization,Fuel Tax Division,if there are que ions. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER 423' <br /> p g g ® ❑ 4.TANK OPERATOR <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) . 106. <br /> r <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 SIGNATUREW DATE 424, 1 PHONE 425. <br /> (925) 884-0800 :2 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Allen Faass California Compliance Manager <br /> +ir <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />