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AWED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> 4on. <br /> TYPE OF ACTION X 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <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 4n4 1 <br /> FACILITY IDN _ <br /> 3 (Agency Use Only) <br /> 3. <br /> BUSINESS NAME(S..FAMTY NAl,re or DBA-Doi g Bulinus Aa) <br /> 7-Eleven #32190 <br /> BUSINESS SITE ADDRESS 103 CITY la <br /> 4943 S. State Hwy. 99 Stockton <br /> 405. <br /> FACILITY TYPE x 1.MOTOR VEHICLE FUELING E] 2.FUEL DISTRIBUTION 403' is the facility located on Indian Reservation or <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? []Yes x No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 409, <br /> 7-Eleven Inc. 805-523-2949 <br /> MARLING ADDRESS aos. <br /> PO Box 711 STATE 4 ZIPCODE 412. <br /> CITY <br /> Dallas TX 75221 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 429.1. PHONE 429-2 <br /> 7-Eleven Inc. 805-523-2949 <br /> 429-3 <br /> MAILING ADDRESS <br /> PO Box 711 4284 STATE 429-5 ZIP CODE a2s 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 /> 416. <br /> MAILING ADDRESS <br /> PO Box 711 <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Dallas TX 75221 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYJDISTRICT ❑ 5.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 Stale Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: ❑ L FACILITY OWNER ❑ 4.TANK OPERATOR <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 compliance with legal re uirements. <br /> APP IGNATURE DATE 4za. PHONE azs. <br /> -1- k-p P (916) 373-1166 <br /> APPLICANT AME(print) 426. APPLICANT TITLE 422 <br /> Dulcinea Webb Compliance Manager <br /> UPCF UST-A Rev.(122007) <br />