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low <br /> 1gFIED PROGRAM CONSOLIDATED FORM �i O <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION q <br /> � � <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT Z 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 4114. FACILITY ID# <br /> 3 (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> 7-Eleven 32262 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 2360 W. Grant Line Rd. Trac <br /> FACILITY TYPE Z 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 /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> 7-Eleven Inc. (916) 463-6776 <br /> MAILING ADDRESS 409. <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 410. STATE 411. ZIP CODE 412. <br /> Dallas TX 75221 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-'- <br /> 7-Eleven Inc. (916) 463-6776 <br /> MAILING ADDRESS 428-3. <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 428-4. 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. 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 Z 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 3 1 1 18 1 g 16 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 /> Z 3.TANK OWNER ❑ 5.FACILITY OPERAT <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) moo---* 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 /> .L /3,�o.0 (916) 463-677 <br /> APPLICANT NAME(print) 426 APPLICANT TITLE 427 <br /> Ian Moorhead Environmental Compliance Manager <br /> °s>3 <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />