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FROM = FAX N0. lay. 04 2002 10:56RM P1 <br /> "VIFlED FROGIRAM CONSOLIDATED <br /> TANKS <br /> UNDERGROUND STORAGE TANKS - FACILITY <br /> (one page per site) Page_of <br /> TYPE_OF ACTION ❑ I.NEW SITE PERMIT 3,RENEWAL PERMIT El 6,CHANGE OF WFORMATION O 7.PERMAI EN LY CLOSED SrTE <br /> (Cheek One dam only) ❑A.AMENDW PERMIT spedry d1M9a 1*001 use oNy ❑ a.TANK REMOVED <br /> 13&TEMPONAItY 61TE cLosuRE Opp <br /> UUWIEUS HAM a <br /> 7-Eleven 17334 <br /> NEAREST CROSS STREET 04�01r1LrFYOW 4.LOCAL GENCY/DI TRICT' <br /> 4501 Pershing Ave, Stockton,CA ® 1.CORPORATION q S.COUNTY AGENCY' <br /> BUSINESS ®1.GAS STATION ❑3.FARM ❑5. 0 MMERCIAL ❑ 2,INDIVIDUAL ❑6.STATE AGENCY- <br /> TYPE 0 2.DISTRIBUTOR ❑4.PROCESSOR 0 6. OTHER ma ❑ 3.PARTNERSHIP 1717.FEDERAL AGENCY- 4oz <br /> TOTAL NUMBER OF TANKS Is facility on Indian Reservation or -P owner ofuSTis a pudic agency:rlBmeasupervi�or awn,SacSon a car <br /> REMAINING AT SITE trustlands? which operates Ne UST(This Is d1e coned person forttle tank records.) <br /> 2 404 ❑ Yes ® No 405 Opp <br /> PROPERTY OWNER NAME 4pa <br /> 7-Eleven, Inc. 208429-8466 <br /> MAILING OR STREET ADDRESS <br /> P.O. Box 711 Attn: Gasoline Acctg. - <br /> CITY 410 STATE 01 ZIP CODE 412 <br /> Dallas TX 75221-0711 <br /> PROPERTY OWNER TYPE 0 1,CORPORATION 2.INDIVIDUAL Lj 4.LOCAL AGENCY/DISTRICT ❑6.STATE AGENCY <br /> ❑9.PARTNERSHIP 5.COUNTY AGENCY E3 7.FEDERAL 413 <br /> TANK OWNER NAME 414 PWONE 415 <br /> 7-Eleven, lnc. zos 429-8466 <br /> MAILING OR STREET ADDRESS 41 <br /> P.O. Box 711 Attn: Gasoline Acctg- <br /> CITY 411 1 STATE 418 ZIP CODE 419 <br /> Dallas TX 75221-0711 <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL U 4.LOCAL AGENCY/DISTRICT 6.STATE AGENCY co <br /> 3.PARTNERSHIP ❑5.COUNTY AGENCY J7.MFEOERAL*Ar-E <br /> HO 44- 3 1 8 a wise. <br /> INDICATE Cl 1.SELF-INSURE ❑4-SURETY BOND [17-STATE FUND ❑1o.LDCAL GOVT MECHANISM <br /> METHOD(,) ❑Z.GUARANTEE ❑5.LETTER OF CREDIT ❑8.STATE FUND&CFO LETTER ❑ 99,OTHER[ <br /> ®3.INSURANCE El 6.EXEMPTION ❑9.STATE FUND&CD 4t1 <br /> Check one box to ndkate w"address should be used for legal notifications and raiding. <br /> Legal nOtifitatioos and mailings arnll be sent to the tank owner unless box 1 or 2 I cnecked. ❑ 1,FACILITY ❑2. PROPERTY OWNER R s.TANK 423 <br /> OWNER <br /> M <br /> z' <br /> Carfifiratiw-I oji)K tat jlta nrormadon provided hereln Is true and accurate to the best or my.knowledge. <br /> SIGNATOR p NT DATE 424 1 PHONE <br /> --4N- <br /> 71121L 2 (208)429-8466 <br /> NAME OF PLI ANT(print) 428 TITLE OF APPLICANT 4a <br /> Bob DeN no Environmental Manager <br /> STATE UST FACILITY NUMBER(Forbealuwanty) 424 1998 UPGRADE CERTIFICATE NUMBER(Fcrwreimeenw 429 <br /> UPCF(1199 revised) Formerly$WRCB Form A <br />