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IFIED PROGRAM CONSOLIDATED FOF <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 ®5.CHANGE OF INFORMATION ❑ ZPERMANENTLY CLOSED SITE <br /> (Check one item only) ❑4.AMENDED PERMIT specify change local use only ❑ 8.TANK REMOVED <br /> ❑ 5 TEMPORARY SITE CLOSURE 400 <br /> I. FACILITY I SITE INFORMATION <br /> BUSINESS NAME(same as FACILITY NAME or DBA-Dong Business As) 3 FACILITY ID# <br /> 1 <br /> 7-Eleven 17334 <br /> NEAREST CROSS STREET 401 FACILITY OWNER TYPE 4.LOCAL GENCY/DISTRICT' <br /> 4501 Pershin Ave, Stockton, CA ® 1.CORPORATION ❑5.COUNTY AGENCY' <br /> BUSINESS 1.GAS STATION 3.FARM Li 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 /> 'L 404 ❑ Yes ® No 405 406 <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407 1 PHONE 408 <br /> 7-Eleven, Inc. 916-463-6776 <br /> MAILING OR STREET ADDRESS Oce <br /> P.O. Box 711 Attn: Gasoline Acctg. <br /> CITY 410 STATE 411 ZIP CODE a1z <br /> Dallas TX 1 75221-0711 <br /> PROPERTY OWNER TYPE 01.CORPORATION ❑2.INDIVIDUAL Ll 4.LOCAL AGENCY/DISTRICT Ll 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. 916-463-6776 <br /> MAILING OR STREET ADDRESS 416 <br /> P.O. Box 711 Attn: Gasoline Acctg. <br /> CITY 417 1 STATE 418 ZIP CODE 419 <br /> Dallas TX 75221-0711 <br /> TANK OWNER TYPE 1.CORPORATION 2.INDIVIDUAL 0 4. LOCAL AGENCY/DISTRICT U 6.STATE AGENCY 42D <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 16 1 Call 916 322-9669 if questions arise 421 <br /> V. PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> INDICATE ❑ 1.SELF-INSURED ❑4.SURETY BOND [:17.STATE FUND [-110. LOCAL GOVT MECHANISM <br /> METHOD(s) [12.GUARANTEE ❑5. LETTER OF CREDIT [IS.STATE FUND&CFO LETTER ❑ 99.OTHER: <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 /> 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 /> SIGNATU$EOF APPLICANT DATE/ 424 PHONE 425 <br /> /7 o; 2-S10 P 916-463-6776 <br /> NAME OF APPLICANT(print) 428 TITLE OF APPLICANT 427 <br /> Ian Moorhead Region Gasoline Environmental Compliance Manager <br /> STATE UST FACILITY NUMBER(For local use only) 428 1998 UPGRADE CERTIFICATE NUMBER(Far local use only) 429 <br /> UPCF (1/99 revised) Formerly SWRCB Form A <br />