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�FIED PROGRAM CONSOLIDATED FOFW <br />TANKS <br />UNDERGROUND STORAGE TANKS - FACILITY <br />(one page per site) Page _ of <br />TYPE OF ACTION ❑ 1. NEW SITE PERMIT ❑ 3. RENEWAL PERMIT 0 &CHANGE OF INFORMATION ❑ 7.PERMANENTLY CLOSED SITE <br />(Check one item only) ❑ 4. AMENDED PERMIT specify change local use only ❑ 8. TANK REMOVED <br />❑ 6.TEMPORARY SITE CLOSURE 400 <br />I. FACILITY/ SITE INFORMATION <br />BUSINESS NAME(Same as FACILITY NAME or DBA -Doing Business AS) 3 FACILITY ID# <br />7 -Eleven 32190 <br />461 FACILITY OWNER TYPE ❑ 4. LOCAL GENCY/DISTRICT" <br />NEAREST CROSS STREET <br />4943 S. State Route 99, Stockton, ® CA 1. CORPORATION ❑ 5. COUNTY AGENCY" <br />BUSINESS ® 1. GAS STATION ❑ 3. FARM ❑ 5. COMMERCIAL ❑ 2. INDIVIDUAL ❑ 6. STATE AGENCY` <br />TYPE ❑ 2. DISTRIBUTOR [14. PROCESSOR ❑ 6. OTHER 403 ❑ 3. PARTNERSHIP ❑ 7. FEDERAL AGENCY' 402 <br />TOTAL NUMBER OF TANKS <br />Is facility on Indian Reservation or <br />"If owner of UST is a public agency: name of supervisor of division, section or office <br />which operates the UST (This is the contact person for the tank records.) <br />REMAINING AT SITE <br />trusbands7 <br />3 404 <br />❑ Yes ® No 405 <br />406 <br />11. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407 <br />PHONE 408 <br />WEC-99-4 LLC <br />MAILING OR STREET ADDRESS 409 <br />15601 Dallas Parkway, Suite 400 <br />CITY 410 STATE 411 ZIP CODE 412 <br />Dallas TX 75001 <br />PROPERTY OWNER TYPE ®1. CORPORATION ❑ 2. INDIVIDUAL Lj 4. LOCAL AGENCY / DISTRICT [16. STATE AGENCY <br />❑ 3. PARTNERSHIP ❑ 5. COUNTY AGENCY [:17. FEDERAL 413 <br />III. TANK OWNER INFORMATION <br />TANK OWNER NAME 414 PHONE 416 <br />7 -Eleven, Inc. as agent for WEC-99-4 LLC 702-270-7160 <br />416 <br />MAILING OR STREET ADDRESS <br />P.O. Box 711 Attn: Gasoline Acct <br />CITY 417 STATE 418 ZIP CODE 419 <br />Dallas TX 75221-0711 <br />TANK OWNER TYPE ® 1. CORPORATION 2. INDIVIDUAL Lj 4. LOCAL AGENCY / DISTRICT ❑ 6. STATE AGENCY 420 <br />❑ 3. PARTNERSHIP [15. COUNTY AGENCY ❑ 7. FEDERAL AGENCY <br />IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY TK HQ 44- 3 1 8 9 6 Call 916 322-9669 if questions arise 421 <br />V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br />INDICATE ❑ 1. SELF-INSURED [:14. SURETY BOND ❑ 7. STATE FUND ❑ 10. LOCAL GOVT MECHANISM <br />METHOD(s) ❑ 2. GUARANTEE ❑ 5. LETTER OF CREDIT ❑ S. STATE FUND & CFO LETTER ❑ 99. OTHER: - <br />422 <br />3. INSURANCE ❑ 6. EXEMPTION ❑ 9. STATE FUND & CD 422 <br />VI. LEGAL NOTIFICATION AND MAILING ADDRESS <br />Check one box to indicate which address should be used for legal notifications and mailing. <br />to the tank owner unless box 1 or 2 is checked. ❑ 1. FACILITY ❑ 2. PROPERTY OWNER ® 3. TANK 423 <br />Legal notifications and mailings will be sent <br />OWNER <br />VII. APPLICANT SIGNATURE <br />Cenificati certify that th n o ation provided herein is true and accurate to the best of my knowledge. <br />SIGNAT OF APPLIC DATE 424 PHONE 425 <br />4.(. 702-270-7160 <br />NAME OF APPLICANT (pri t) 426 TITLE OF APPLICANT 427 <br />Gasoline & Environmental Compliance Manager <br />Shane Partridge <br />STATE UST FACILITY NUMBER (Forlocal useonly) 428 <br />1 1998 UPGRADE CERTIFICATE NUMBER (Forlocal useonly) <br />429 <br />UPCF (1/99 revised) Formerly SWRCB Form A <br />