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FIED PROGRAM CONSOLIDATED F <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (Ona form per facility) <br /> TYPE OF ACTION X 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> 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# <br /> 3 (Agency Use Only) <br /> BU$INE$$NAME(Same es FACa.ITY NAME m DBA-Ibivg Bueinesa As) <br /> 7-Eleven #32190 <br /> BUSINESS SrM ADDRESS 103 CITY 100' <br /> 4943 S. State Hwy. 99 Stockton <br /> FACILITY TYPE x 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 x No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 008 <br /> 7-Eleven Inc. 805-523-2949 <br /> MAILING ADDRESS 409. <br /> PO Box 711 <br /> CITY 410 STATE 411 ZIP CODE 412. <br /> Dallas TX 75221 <br /> HI. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 42s-1. PHONE 428-2 <br /> 7-Eleven Inc. 805-523-2949 <br /> 428-3 <br /> MAILING ADDRESS <br /> PO Box 711 4284 STATE 428-5 ZIP CODE 42s 6 <br /> CITY <br /> Dallas TX 75221 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> 7-Eleven Inc. 805-523-2949 <br /> MAILING ADDRESS 416. <br /> PO Box 711 <br /> CITY 417. STATE 418, 1 ZIP CODE 419. <br /> Dallas TX 75221 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY X 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 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: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> X 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 406. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VH.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full com liance with legal requirements. <br /> APPLIC N DATE 424. PHONE 425. <br /> V-b-(,5 (916) 373-1166 42 <br /> APPLICANT N print) 426. APPLICANT TITLE <br /> Dulcinea Webb Com liance Manager <br /> UPCF UST-A Rev.(12/2007) <br />