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i <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ® 1 . NEW PERMIT ❑ 5. CHANGE OF INFORMATION ❑ 7. PERMANENT FACILITY CLOSURE 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 404. FACILITY ID # 1 <br /> 3 (Agency Use Only) 3 8 - 7 0 4 <br /> BUSINES S NAME (Same as FACILrIY NAME or DBA - Doing Business As) 3, <br /> 7- Eleven , Inc Store #41531 <br /> BUSINESS SITE ADDRESS 103 . CITY 104• <br /> 3379 N Tracy Blvd , Tracy <br /> FACILITY TYPE N 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? ❑ Yes N No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 408. <br /> 7- Eleven , Inc 916 742-0232 <br /> MAILING ADDRESS 409. <br /> P . O . Box 0711 - Attn : Gasoline Compliance <br /> CITY 410. STATE 411• ZIP CODE 412. <br /> Dallas TX 75221 -0711 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4284 • PHONE 428-2 <br /> 7- Eleven , Inc ( 916 ) 742 - 0232 <br /> MAILING ADDRESS 428-3 <br /> P . O Box 0711 - Attn : Gasoline Compliance <br /> CITY 428-4 STATE 428-5 ZIP CODE 428-6 <br /> Dallas TX 75221 -071 1 <br /> IV, TANK OWNER INFORMATION <br /> TANK OWNERNAME 414. PHONE 415, <br /> 7- Eleven , Inc - Attn : Gasoline Compliance ( 916 ) 742 - 0232 <br /> MAILING ADDRESS 416, <br /> P . O . Box 0711 - Attn : Gasoline Compliance <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Dallas TX 75221 -071 1 <br /> OWNER TYPE: ❑ 4. LOCAL AGENCY/DISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. <br /> ❑ 7. FEDERAL AGENCY N 8, NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY (TK) HQ 44- 10 13 1 1 1 8 19 1 8 1 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: N 1 , FACILITY OWNER ❑ 4. TANK OPERATOR 423 <br /> N 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 /> APPLICANT SIGNATURE DATE 424• PHONE 425. <br /> 916 ) 742 - 0232 <br /> APPLICANT NAME (print) 426. APPLICANT TITLE 427 <br /> Crystal Justice Construction Manager <br /> UPCF UST-A Rev. (12/2007) <br />