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IFIED PROGRAM CONSOLIDATED FO <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ B.TANK REMOVED <br /> ❑sTEMPORARY SITE CLOSURE 400 <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Berne as FACILITY NAME or DBA-Doing Business As) 3 FACILITY IDI 1 <br /> 7-Eleven 14117 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> 2725 Count Club Blvd., Stockton, CA ® 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS ® 1.GAS STATION ❑3.FARM ❑ 5. COMMERCIAL ❑ 2. INDIVIDUAL [16.STATE AGENCY" <br /> TYPE ❑2.DISTRIBUTOR Cl 4.PROCESSOR❑6. OTHER 403 ❑ 3. PARTNERSHIP ❑7.FEDERAL AGENCY- 402 <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or -if owner of UST is a public agency:name of supervisor of division,section or office <br /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 2 404 ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4D] PHONE 408 <br /> 7-Eleven, Inc. 916-463-6776 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. Box 711 Attn: Gasoline Acctg. <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Dallas TX 75221-0711 <br /> PROPERTY OWNER TYPE M1.CORPORATION 2.INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT El 6.STATE AGENCY <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7.FEDERAL 413 <br /> III.TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 7-Eleven, Inc. 916-463-6776 <br /> MAILING OR STREET ADDRESS 4fs <br /> P.O. Box 711 Attn: Gasoline Acctq. <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Dallas TX 75221-0711 <br /> TANK OWNER TYPE ® 1.CORPORATION 2.INDIVIDUAL ❑4. LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 42D <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY ❑7. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 3 1 8 9 6 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED ❑4.SURETY BOND [17.STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2. GUARANTEE ❑5.LETTER OF CREDIT ❑ 8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> - <br /> [D 3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications and mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY [12. PROPERTY OWNER ®3.TANK 423 <br /> OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE/ 424 PHONE azs <br /> R 916463-6776 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 4z� <br /> Ian Moorhead I Region Gasoline Environmental Compliance Manager <br /> STATE UST FACILITY NUMBER(For local use only) 428 1 1998 UPGRADE CERTIFICATE NUMBER(For local me only) 42g <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />