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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION— FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ L NEW PERMIT ® 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4i20 <br /> t'Check one item only/ ❑ ; RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> TOTAL NUMBER OF USTs AT FACILITY 404 FACILITY ID t! 1 t" <br /> 4 (agency Use Only) <br /> BUSINESS NAME(Same as FacilityName or DBA—Doing Business,4s) 3, <br /> Circle K/76#2705447 <br /> BUSINESS SITE ADDRESS 1003 CITY 104 <br /> 1469 E. Hammer Lane Stockton <br /> FACILITY TYPE ® i.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403 Is the facility located on Indian Reservation or '°$ <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands'? ® 1.Yes ® 2.No <br /> PROPERTY OWNER NAME 407 PHONE 44$ <br /> Convenience Retailers LLC. 281 293-5101 <br /> MAILING ADDRESS 4W <br /> 600 N. Dairy Ashford, Suite TA 1138B <br /> CITY ii0 STATE 411 ZIP CODE 4t2 <br /> Houston TX 77079 <br /> III:` TANK <br /> 01 FERATOR Il�fFOI?t "IQN <br /> TANK OPERATOR NAME 428-1_ PHONE 425= <br /> Convenience Retailers LLC. 1 (281) 293-5101 <br /> MAILING ADDRESS 428•3 <br /> 600 N. Dairy Ashford, Suite TA 1138B <br /> CITY 428-4 STATE 428-5 ZIP CODE 42" <br /> Houston TX 7}y7079 <br /> TANK OWNER NAME 414 PHONE 415 <br /> Convenience Retailers LLC. (281) 293-S 101 <br /> MAILING ADDRESS 416 <br /> 600 N. Dairy Ashford, Suite TA 1138B <br /> CITY 417 STATE 418 ZIP CODE 414- <br /> Houston I TX 77019 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 4W <br /> ❑ 7.FEDERAL AGENCY ® 3.NON-GOVERNMENT <br /> QID`.; QII .I ►TI `U.SIT— <br /> TY(TK)HQ 44- 2 5 7 9 9 9 Carl the State Board of Equalization.Fuel Tax Division,if there are questions. 421 <br /> ' .P IT MOLDER Imo!] TI0 <br /> Issue permit and send legal notifications and mailings to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 423, <br /> ® 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Requiredfor Public Agencies Only) 41A <br /> 777777 <br /> I, <br /> '�`II:APPLI�AN'T SI�i�A <br /> CERTIFICATION: I certify that the information provided herein is true,accurate,and in full coon fiance with le al requirements. <br /> APPLICANT SIGNATURE DATE i24 PHONE 425 <br /> 7/10/2008 970) 692-4257 <br /> ANT NAME(print) 426 APPLICANT TITLE 427 <br /> Tim Wind Project Manager/Agent for Owner <br /> UPCF UST-A Rev.(11./2007)-1/2 www.unidoes.org <br />