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I <br /> TIED PROGRAM CONSOLIDATED FOFq <br /> TANKS <br /> ` UNDERGROUND STORAGE TANKS r FACILITY V�`�'` <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 ❑ 8 TANK REMOVED <br /> ❑&TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY I SITE INFORMATION <br /> BUSINESS NAME(same as FACILITY NAME or DBA-Doing Business As) 3 FACILITY ID# - <br /> 7-Eleven 14117 �I 1 <br /> r <br /> NEAREST CROSS STREET 401 FACILITY OWNER T E ❑4. LOCAL GENCY/DISTRICT* <br /> 2725 Country Club Blvd., Stockton, CA 0 1.CORPORATION ❑5.COUNTY AGENCY* <br /> BUSINESS 0 1.GAS STATION ❑3. FARM ❑ 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY* <br /> TYPE [-12.DISTRIBUTOR ❑4. PROCESSOR❑6. OTHER 403 ❑ 3.PARTNERSHIP [17. 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 &ustlands? which operates the UST(This is the contact person for the tank records.) <br /> 2 404 ❑ Yes ® No 405 405 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 408 <br /> 7-Eleven, Inc. 253-796-7170 <br /> MAILING OR STREET ADDRESS 409 <br /> P.O. Box 711 Attn: Gasoline Acct . <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Dallas TX 75221-0711 <br /> PROPERTY OWNER TYPE ® 1.CORPORATION ❑ 2.INDIVIDUAL ❑4. LOCAL AGENCY I DISTRICT ❑ 6.STATE AGENCY <br /> ❑ 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7.FEDERAL 413 <br /> III. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 7-Eleven, Inc. 253-796-7170 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O. Box 711 Attn: Gas©line Acct . <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Dallas TX 75221-0711 <br /> TANK OWNER TYPE ® 1. CORPORATION ❑ 2.INDIVIDUAL ❑4. LOCAL AGENCY I DISTRICT ❑ 6.STATE AGENCY 420 <br /> ❑ 3.PARTNERSHIP ❑5.COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 3 1 1 8 19 6 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7. STATE FUND 0 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 /> Vt. 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 ❑2. PROPERTY OWNER ®3,TANK 423 <br /> OWNER <br /> VII. APPLICANT SIGNATURE <br /> Certification- ertif)!,that the info ation pr ided herein is true and accurate to the best of my knowledge. <br /> SIGNAT E 5 A PLI NT DATE 424 PHONE 425 <br /> 253-796-7170 <br /> NAME 9P APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Randy Martin Environmental Manager <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For kcal use only) 429 <br /> UPCF (1199 revised) Formerly SWRCB orm A <br />