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MN <br /> rq7410 <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACI ION (] 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (C hmk nne item only) ® 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404 1 FACILITY ID# _ _ 1 <br /> 5 A enc Use Only) <br /> BUSINESS NAME(Same n FACILITY NAIL or DBA-Doi%Businrss As) 3. <br /> Love's Travel Stop#223 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 1553 Colony Road Ripon <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> 3.FARM ❑ 4.PROCESSOR C3 6.OTHER Trust lands? ❑Yes ®No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 40T PHONE 409. <br /> Love's Country Stores of California 405)242-2455 <br /> MAILING ADDRESS 409. <br /> PO Box 26210 <br /> CITY 410. 1 STATE 411 7,IPCODF 412. <br /> Oklahoma City OK 73126 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 429-2 <br /> Love's Country Stores of California (405)242-2455 <br /> MAILING ADDRESS 4za s <br /> PO Box 26210 <br /> CITY 429-0 1 STATE -5 ZIP CODE 428-6 <br /> Oklahoma City OK 73126 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414 1 PHONE 415. <br /> Love's Country Stores of Califomia (405)242-2455 <br /> MAILING ADDRESS 416. <br /> PO Box 26210 <br /> CITY 417,1 STATE 41a. 1 ZIP CODE 419 <br /> Oklahoma City OK 73126 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCYIDISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1014101718121 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI.PERMIT HOLDER INFORMATION <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(Required For Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that the information provided herein is true,accurate and in full compliance with legal re uirements. <br /> APPLICANT SIGNATURE DATE 424, PHONE 425. <br /> C. <br /> K�Vlv1 NIGH 2/2_4/2009 (405)242-2455 <br /> WPPrICANT NAME(print) 426 APPLICANT TITLE 427 <br /> C.Kevin Nickelld Enviromnental Compliance Analyst <br /> UPCF UST-A Rev.(12/2007) s' _ <br />