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Utr TIED PROGRAM CONSOLIDATED FOR <br /> !TANKS t <br /> UNDERGROUND STORAGE TANKS - Fq <br /> (on page per -.., <br /> bf <br /> TYPE OF ACTION [1 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.CHANGE OF INFORMATION SITE <br /> 4.AMENDED PERMIT specify change local use only <br /> (Check one item only) ❑ �� <br /> ❑6.TEMPORARY SITE CLOSURE 400 <br /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Same ss FACILITY NAME or DBA-Doing Business As) a FACILITY ID# t <br /> 7-Eleven 32190 <br /> NEAREST CROSS STREET 4o1 FACILITY OWNER TYPE ❑4.LOCAL GENCY/DISTRICT' <br /> 4943 S State Route 99, Stockton, CA �4 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS ❑1.GAS STATION [13.FARM ❑5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY' <br /> TYPE ❑2.DISTRIBUTOR ❑4.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 /> REMAINING AT SITE trustlands? which operates the UST(This is the contact person for the tank records.) <br /> 3 404 ❑ Yes ® No 405 406 <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTYOWNER NAME 401 PHONE 408 <br /> WECI-99-4 LLC 972-361-5000 <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 ❑4.LOCAL AGENCY/DISTRICT [-16.STATE AGENCY <br /> ❑3.PARTNERSHIP [15.COUNTY AGENCY [17.FEDERAL 413 <br /> TANK OWNER NAME !I It PHONE 415 <br /> WECI-99-4 LLC 972-361-5000 <br /> 416 <br /> MAILING OR STREET ADDRESS <br /> 15601 Dallas Parkway, Suite 400 <br /> CITY 417 STATE 418 ZIP CODE 419 <br /> Dallas TX 75001 <br /> TANK I;;IIi i;ii r9TIJAIRPORATION 2.INDIVIDUAL 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY ago <br /> ❑ 3.PARTNERSHIP [15.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 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED F1 4.SURETY BOND ❑7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE [15.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> 3.INSURANCE 716.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 /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY [12. PROPERTY OWNER X3.TANK 423 <br /> OWNER r <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the interna n vid herein is true and accurate to the best of my knowledge. <br /> SIGNATURE OF APPLICANT DATE 424 PHONE 425 <br /> �3�� 503-977-7713 <br /> NAME OF APPLICANT(pdn 426 TITLE OF APPLICANT 427 <br /> Bob DeNinno Environmental Manager, 7-Eleven, Inc. <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) a29 <br /> UPCF(1/99 revised) • • Formerly SWRCB Form A <br />