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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT M 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE °00' <br /> (Check one ire.only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE <br /> ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY " FACILITY ID# t' <br /> 2 (Agency Use Only) / <br /> BUSINESS NAME(Same as Facility Now or DBA-Doing Business As) 3- <br /> 7-Eleven 17334 <br /> BUSINESS SITE ADDRESS 103. CITY 1M- <br /> 4501 Pershing Ave Stockton <br /> FACILITY TYPE ® L MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or ws. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTI IER Trust(ands? ❑ 1.Yes M 2.No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407. PHONE 4K <br /> 7-Eleven Inc. (916) 463-6776 <br /> MAILING ADDRESS aro. <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY 41a STATE 411, ZIP CODE 41', <br /> Dallas TX 75221 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 4'-8-1. PHONE 4'-d'-- <br /> 7-Eleven Inc. (916) 463-6776 <br /> MAILING ADDRESS 428.3. <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY a'-e-a. STATE 4�5. ZIP CODE 428-6. <br /> Dallas TX 75221 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNERNAME 434. PHONE 415. <br /> 7-Eleven Inc. (800) 828-0711 <br /> MAILING ADDRESS 416_ <br /> P.O. Box 711 Attn: Environmental Department <br /> CITY an. 1 STATE 418. ZIPCODE 419, <br /> Dallas TX 75221 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4-0. <br /> ❑ 7.FEDERAL AGENCY M 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 13111819161 1 Call the Slate Board of Equalization,Fuel Tax Division,if there are questions. 4'1 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER6'3 <br /> ❑ 4.TANK OPERATOR <br /> M 3.TANK OWNER ❑ 5.FACILITY OPERATOR. <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) a16. <br /> VII. APPLICANT SIGNATUREse'a <br /> CERTIFICATION: I certify that the information provided herein is true accurate,and in full compliance with legal re uirement§:-- <br /> APPLICANT SIGNATURE DATE 424 PHONE 425, <br /> '_z./7e/aJP (916)463-677 <br /> APPLICANT NAME(print) 426- APPLICANT TITLE 417 <br /> Ian Moorhead Environmental Compliance Manage, <br /> UPCF UST-A Rev.(1212007)-1/2 www.unidocv.org <br />