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Vill <br /> TIED PROGRAM CONSOLIDATED FORE' �[ TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE OF ACTION ❑ 1.NEW SITE PERMIT ❑3.RENEWAL PERMIT ®5.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 /> 1. FACILITY/SITE INFORMATION <br /> BUSINESS NAME(Sameas FACILITY NAMEar DRA-Doing business As) 3 FACILITY ID# 1 <br /> 7-Eleven 17334 <br /> NEAREST CROSS STREET bo1 FACILITY OWNER TYPE Li 4.LOCAL GENCY/DISTRICT' <br /> 4501 Pers.Nn AVe, SYOCkton' CA 10 1.CORPORATION ❑5.COUNTY AGENCY- <br /> BUSINESS ® 1.GAS STATION Y FARM 5. COMMERCIAL ❑ 2.INDIVIDUAL ❑6.STATE AGENCY` <br /> TYPE [12.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 /> 2 404 ❑ Yes ® No 405 406 <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 PHONE 406 <br /> 7-Eleven, Inc. 253-796-7170 <br /> MAILING OR STREET ADDRESS d09 <br /> P.O. Box 711 Attn: Gasoline Acctg. <br /> CITY 410 STATE 411 ZIP CODE 412 <br /> Dallas TX 75221-0711 <br /> PROPERTY OWNER TYPE 01I.CORPORATION E12.IN0IVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY <br /> ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY [17.FEDERAL 413 <br /> 111. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 PHONE 415 <br /> 7-Eleven, Inc. 253-796-7170 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O. Box 711 Attn: Gasoline Acctg. <br /> CITY 417 1 STATE 416 ZIP CODE 419 <br /> Dallas TX 75221-0711 <br /> TANKOWNERTYPE 1.CORPORATION El 2. INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT 0 6.STATE AGENCY 420 <br /> ❑ 3. PARTNERSHIP ❑5.COUNTY AGENCY ❑7.FEDERAL AGENCY <br /> IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 3 1 1 18 19 j 6 1 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑7.STATE FUND [110.LOCAL GOVT MECHANISM <br /> METHOD(s) ❑2.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99.OTHER: <br /> - <br /> [D 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 /> Legal notifications and mailings will be sent to the tank owner unless box 1 or 2 is checked. ❑ 1.FACILITY ❑2. PROPERTY OWNER ®3.TANK 423 <br /> OWNER <br /> VII.APPLICANT SIGNATURE <br /> Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. <br /> SI TURE OF APPLICANT DATE 424 PHONE 42s <br /> 253-796-7170 <br /> NAME OF APPLICANT(print) 426 TITLE OF APPLICANT 427 <br /> Randy Martin Environmental Manager <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local use only) 429 <br /> UPCF(1/99 revised) Formerly SWRCB Form A <br />