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�I 1/0 <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />upeF usT <br />UNDERGROUND STORAGE TANI( <br />OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br />(One form per facility) <br />TYPE OF ACTION XI. NEW PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE <br />400. <br />(Check one item only) ❑ 3. RENEWAL PERMIT ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION <br />TOTAL NUMBER OF USTS AT FACILITY 464. FACILITY IDN <br />(Agency Use 011)J <br />BUSINESS NAME (Same as FACILITY NAME or DBA — Doing Business As) <br />7 -Eleven, Inc <br />BUSINESS SITE ADDRESS 103. <br />CITY <br />104' <br />t5 1 t5 k4 a4 <br />Stockton <br />FACILITY TYPE 1, MOTOR VEHICLE FUELING 1. FUEL DISTRIBUTION A03' <br />Is the facility located on ndi 1 Reservation or <br />405. <br />El 3, FARM [:14. PROCESSOR El6.OTHER <br />Trust lands? El Yes No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 4076 <br />PHONE <br />408, <br />71mmEleven, Inc. <br />916 742mO232 <br />MAILING ADDRESS <br />409' <br />3200 Hackberry Rd <br />CITY 41°, <br />STATE 411, <br />ZIP CODE <br />412, <br />Irving <br />TX <br />75063 <br />III. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428'1. <br />PHONE <br />4284 <br />�1 <br />MAILING ADDRESS <br />28 a <br />CITY 428'4 <br />STATE 428.5 <br />ZIP CODE <br />428.6 <br />JAS! 2 7 2020 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />r1i(PIVI RONM <br />__NI /! L HEALTH <br />415, <br />SL2-/12�C� <br />E'A L T%4 - �.� I <br />MAILING ADDRESS <br />416' <br />CITY 417, <br />STATE 418, <br />ZIP CODE <br />419. <br />OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY <br />420. <br />❑ 7. FEDERAL AGENCY 8. NON-GOVERNIv1ENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TIC) HQ 44- <br />r <br />Call the State Board of Equalization, Fuel Tax Division, if there are questions, <br />421' <br />VI. PERMIT HOLDER INFORMATION <br />Issue permit and send legal notifications and mailings to: �I. FACILITY OWNER ❑ 4. TANK OPERATOR <br />423 <br />❑ 3. TANK OWNER ❑ 5. FACILITY OPERATOR <br />406. <br />SUPERVISOR OF DIVISION, SECTION, OR OFFICE (Required For Public Agencies Only) <br />VII, APPLICANT SIGNATURE <br />CERTIFICATION: I certify that the information provided herein is true, accurate, and in full compliance with legal requirements. <br />AP LI,QANT SIGNATURE <br />DATE 424• <br />PHONE <br />425• <br />of � iv <br />APPLICA NAM print) 426• <br />7 <br />APPLICANT TITLE 427 <br />�� t t,,� P (�Z7 TAt7 # Ass 0007E�S <br />-A Rev. (1212007) <br />