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IED PROGRAM CONSOLIDATED FO Tq049 <br /> '� <br /> UNDERGROUND STORAGE TANKS - FACILITY(one page per site) ag _ <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT D 3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION D 7.PERMANENTLY CLOSED SITE <br /> (Check one item only) [14.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I, FACILITY/SITE INFORMATION <br /> BUSINESS NAME ISameas FACILITY NAME or DBA-Doing Business AS) 3 FACILITY ID# O 1 <br /> 7-Eleven 14117 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> 2725 COUnt CIUb 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 ❑4.PROCESSOR[16. 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 407 PHONE 408 <br /> 7-Eleven, Inc. 702-270-7160 <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 91.CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑ 3.PARTNERSHIP ❑5.COUNTY AGENCY [17. FEDERAL 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 7-Eleven, Inc. 702-270-7160 <br /> 416 <br /> MAILING OR STREET ADDRESS <br /> P.O. Box 711 Attn: Gasoline Acctg. <br /> CITY 417 STATE 418 ZIP CODE 41s <br /> Dallas TX 75221-0711 <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑5.COUNTY AGENCY [17. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 3 1 1 18 1 9 1 6 1 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE [-11.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 /> ®3. INSURANCE ❑6.EXEMPTION ❑ 9.STATE FUND&CD 422 <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one boz 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 /> Ce fi tion-I certify at he information provided herein is true and accurate to the best of my knowledge. <br /> SIG RE OFA NT DATE_ 424 PHONE 425 <br /> 702-270-7160 <br /> NAME OF APPLICA (p 426 TITLE OF APPLICANT 427 <br /> Shane Partridge Gasoline & Environmental Compliance Manager <br /> STATE UST FACILITY NUMBER(Forlocal useonly) 428 1998 UPGRADE CERTIFICATE NUMBER(Forlocal useomy) 429 <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />