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............... <br /> 11 11 MEMO,,ow 1 111111111 11 1 1 11 <br /> UNIFIED PROGRAM CONSOLIDATED FORM JUL 2 7 2012 <br /> UNDERGROUNDSTORAGE TALK <br /> OPERATING PERMIT APPLICATION— FACILITY INFO"ATION <br /> (One form per facility) <br /> TYPE OF ACTION 0 1.NEW PERMIT 5,CHANGE OF INFORMATION C1 7,PERMAN17NT—FAC <br /> Ct lCheck one aemonly) ❑ 3,RENEWAL PERMIT ❑ 6,TEMPORARY FACILITY CLOSURE 0 9,"TRANSFER PERMIT <br /> 1. FACILITY INFORMATION <br /> W—YFAI.NUMB--� OF LISTS AT FACILITY arwFACILITY ID 4 <br /> 2 L(,4geny Uw Only) <br /> --I USINLSS—NIAME',tSoine as Factlit it <br /> yNat e or DBA Doing Business As) <br /> C Stet 5449W4 <br /> BUSINESS SITE ADDRESS CITY <br /> 322 S. Center St. Stockton 403 <br /> FACILITYTYPF 0 1,MOTOR VI UIE <br /> ict.r FUELING 0 2.FL DISTRIBUTION Is die facility located on Indian Reservation or <br /> IER Trust lands? 0 1.Yes 0 21 No <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME, 407 1 PHONE <br /> Convenience Retailers, LLC (925) 884-0800 — <br /> 405 <br /> 7180 Kull Center Pkwy 4io STXIT 4 412, <br /> CITY -'P <br /> 17 <br /> Pleasanton CA 94566 <br /> 111. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 421:1 PHONE 42$-2 <br /> Convenience Retailers, LLC (925) 884-0800 419.3 <br /> MAILING ADDRESS <br /> 7180 Koll Center Pk_._ 428-5 ZIPCODE 4284� <br /> CITY 1114 1 STATE <br /> Pleasanton CA 94566 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME, PHONE 411 <br /> Convenience Retailers, LLC (925) 884-0800 <br /> MAILING ADDRESS <br /> 7180 loll Center Pk <br /> 411 <br /> CITY STATE ON ZIP CODE <br /> Pleasanton CA 1 94566 <br /> OWNER TYPE 4.LOCAL AGENCY/DISTRICT 0 5,COUNTY AGENCY [3 6,STATE AGENCY 410 <br /> 0 7.FFDERAL AGENCY ED 8.NoN-GoviummENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> Ty jKj HQ 44-- Lq j� 6 3 $ 14 Cal I the State Board of Equalization,Fuel Tax Division,if there arc*cs ions._ — <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue penint and send legal notifications and mailings,tw 0 1,FAcit-rry OWNER 0 4.TANK OPERATOR. 423 <br /> 0 3.TANK OWNER 0 5.FACILITY OPERATOP <br /> SUPFRVISOR Ol`r)]Vl'S )N-,SECTION,OR OFFICE(Requiredfor Public Age"ch's Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I-certify that the information provided herein is true,accurate,and in full compliance with le al reaulremeats. <br /> APPLICANT SIGNATURE DAVE, 424 1 PHONE 425 <br /> 2- ) 884-0800 <br /> APPLICANT NAME(print) 4xc APPLIC ANT TITLE <br /> Allen Faass California Com plianceMla�njer.... <br /> U,PCF UST-A Rev.(12/2007)-t/2 -www,uwidocs,org <br />