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� ' r rn wren ef1� i r\ <br />LIED PRO(iKAM l.vrvavi.rv.,r a..., . •-••-( L/- • ,;, r T'ANKS <br />UNDERGROUND STORAGE TANKS - --OW Y%itj'3O b <br />(one page per site) Page _ of <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT ® 6.CHANGE OF INFORMATION ❑ TPERMANENTLY CLOSED SITE <br />❑ e. TANK REMOVED <br />(Check one Item only) ❑ 4. AMENDED PERMIT specify change local use only <br />400 <br />[I6.TEMPORARY SITE CLOSURE <br />I. FACILITY I SITE INFORMATION hi (�S(i �J `" 1 0 g <br />BUSINESS NAME (same as FACILITY NAME or DBA- Doing Business As) 3 FACILITY ID# O 1 <br />7 -Eleven 32190 4ot FACILITY OWNER TYPE ❑ 4. LOCAL GENCY/DISTRICT` <br />NEAREST CROSS STREET <br />❑ <br />®1. CORPORATION 5. COUNTY AGENCY' <br />4943 S. State Route 99, Stockton, CA <br />[9 GAS STATION 3. FARM 5. COMMERCIAL ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY' <br />BUSINESS <br />TYPE [12. DISTRIBUTOR [14. PROCESSOR ❑ 6. 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 />which operates the UST his is the contact person for the tank records.) <br />REMAINING AT SITE trustlands7 <br />406 <br />3 404 ❑ Yes ® No 405 <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 PHONE 406 <br />WEC-99-4 LLC 409 <br />MAILING OR STREET ADDRESS <br />15601 Dallas Parkwa , Suite 400 410 STATE 411 ZIP CODE 412 <br />CITY <br />1 TX 75001 <br />Dallas <br />PROPERTY OWNER TYPE ®1. CORPORATION ❑ 2. INDIVIDUAL 4. LOCAL AGENCY /DISTRICT El 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. as a Ent for WEC-99-4 LLC 702-270-7160 <br />416 <br />MAILING OR STREET ADDRESS <br />P.O. Box 711 Attn: Gasoline Acct 4t9 <br />STATE 418 ZIP CODE <br />CITY 417 <br />TX 75221-0711 <br />Dallas DISTRICT azo <br />TANK OWNER TYPE ®1. CORPORATION 4. LOCAL AGENCY / <br />6. <br />E1 3. PADRTNDUAL <br />E SHIP El 5. COUNTY AGENCY ❑ FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HO 44- 3 1 8 9 6 Call 916 322-9669 if uestions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE ®1. 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: azz <br />❑ 3. INSURANCE ❑ 6. EXEMPTION El9. STATE FUND & CD <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and mailing. 423 <br />be to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY [12, PROPERTY OWNER ® 3. TANK <br />Legal notifications and mailings will sent <br />OWNER <br />VII. APPLICANT SIGNATURE <br />Certification i that then provided herein is true and accurate to the best of my knowledge. <br />a25 <br />424 PHONE <br />SIGNATUR PPLI DATE <br />702-270-7160 <br />427 <br />426 <br />NAME OF A ri IC int) <br />TITLE OF APPLICANT <br />Gasoline &Environmental Compliance Manager <br />Shane Partridge <br />STATE UST FACILITY NUMBER (For local use only) 428 <br />1998 UPGRADE CERTI FICATE NUMBER (For local use only) 429 <br />UPCF (1/99 revised) Formerly SWRCB Form A <br />