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D PROGRAM CONSOLIDATED F <br /> UNDERGROUND STORAGE T <br /> ANKS - FA I1'I� <br /> TYPE OF ACTION (One page per site) Page_of <br /> (Check one item only) 1 NEW PERMIT ®3.RENEWAL PERMIT <br /> El4.AMENDED PERMIT (Specify❑ngcha ,RANGE OF INFORMATION ❑7.PERMANENTLY CLOSED SITE 400. <br /> ❑6.TEMPORARY SITE CLOSURE ❑s.TANK REMOVED <br /> 02 ZLfC, I. FACILITY/SITE INFORMATION <br /> BU$INE$S NAMES-as FACILITY NAME or DRA-Doing Business As) 3, FACILITY <br /> R der Trans ortation Services #1071 ID# v' <br /> NEAREST CROSS STREET O i <br /> Duck CIeek 401, FACILITY OWNER TYPE ❑4.LOCAL AGENCY/DISTRICT• 402. <br /> BUSINESS ❑ 1.GAS STATION 3.FARM ®1.CORPORATION E]5.COUNTY AGENCY* <br /> TYPE ❑2.DISTRIBUTOR ®5.COMMERCIAL 403. ❑2.INDIVIDUAL <br /> ❑4.PROCESSOR El 6.OTHER ❑6.STATE AGENCY* <br /> TOTAL NUMBER OF TANKS 404. ❑3.PARTNERSHIP ❑7.FEDERAL AGENCY* <br /> REMAINING AT SITE Is facility on Indian Reservation 405. *If owner of UST is a public division,section or 496. <br /> 4 or trust lands? office which operates the UST.agency: name of supervisor of d <br /> El Yes ®No contact(This is the person for the tank records.) <br /> 11 PROPERTY OWNER INFORMATION <br /> PROPERTY O WNER NAME <br /> R der Trans ortation Services 407. PHONE <br /> MAILING OR STREETADDRESS 408. <br /> 713-426-4800 <br /> P.O. Box 70737 <br /> CITY 409. <br /> Houston 410. STATE 411, ZIP CODE <br /> TR 77270 41z <br /> PROPERTY OWNER TYPE I.CORPORATION 2.INDIVIDUAL <br /> ❑4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY 413. <br /> ❑3.PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> TANK O WNER NAME M. TANK OWNER INFORMATION <br /> R der Trans ortation Services 414. PHONE <br /> MAILING OR STREET ADDRESS 713-426-4800 415. <br /> P.O. Box 70737 416. <br /> CITY <br /> Houston 417. STATE 41 e. ZIP CODE <br /> 419. <br /> TANK OWNER TYPE ® 1.CORPORATION ❑2.INDNIDUAL TX 7727[1 <br /> ❑4.LOCAL AGENCY/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- Call 916 322-9669 if questions arise <br /> ay. <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE METHOD(s) ❑I.SELF-INSURED ❑4.SURETY BOND <br /> ❑2.GUARANTEE ❑7.STATE FUND ❑10.LOCAL GOVT MECHANISM <br /> ❑5.LETTER CREDIT [:]8.STATE FUND&CFO LETTER ❑99.OTHER: 4R_ <br /> ®3.INSURANCE ❑6.EXEMPTION ❑9.STATE FUND&CD - <br /> VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br /> Check one box to indicate which address should be used for legal notifications arM mailing. <br /> Legal notifications and mailings will be sent to the tank owner unless box I or 2 is checked. ❑ 1.FACILITY <br /> ❑2. PROPERTY OWNER ®3.TANK OWNER 423. <br /> VII. APPLICANT SIGNATURE <br /> Certification: I certify that i ormafi n provided h in is true and accurate to the hest of my knowledge. <br /> SI ICA T <br /> DATE 424. PHONE 425- <br /> April 4, <br /> uApri14,2007 713426-4800 <br /> Amy OF APP I T(print) 426 TITLE OF APPLICANT <br /> Y Compliance Manager 4277 <br /> STATE UST FACILITY NUMBER(Agency...,y) 428. <br /> 1998 UPGRADE CERTIFICATE NUMBER(Agency use only) 429. <br /> (See Data Element 1,above. <br /> UPCF Hwfwrc-a(1/99).1/2 www,unidocs.org <br /> Rev.02/16/00 <br />