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IFIED PROGRAM CONSOLIDATED FO <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OFA ON ❑ I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item mIy) ® 3.RENEWAL PERMIT <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUM ER OF USTs AT FACILITY 4N. FACILITY ID# <br /> 1 Agency Use Ont <br /> BUSINESSN E(S.m .FACMITYNAWEo --A-Doivg Business As) 3 <br /> TSI Trans-S, tem, hlc <br /> BUSINESS SITE ADDRESS X03. CITY m4. <br /> 707 E Roth Road French Camp <br /> FACILITY T ® I.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403' Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes ®No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY O ER NAME 407� PHONE 403. <br /> TSI Trans System Inc. (800) 5414213 <br /> MAILING AD KESS 409 <br /> 7405 S Hayf'rd RD <br /> CITY 410. STATE 411. <br /> ZIP CODE 412. <br /> Cheney WA 99004 <br /> HL TANK OPERATOR INFORMATION <br /> TANK OPERTI OR NAME 428-1. PHONE 428-2 <br /> TSI Trans Sy Item Inc. (800) 5414213 <br /> MAILING ADD RESS 428-3 <br /> 7405 S Hayfird RD <br /> CITY42s-0 STATE 4za-s <br /> ZIP CODE 428-s <br /> Cheney WA 99004 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNER AME 414. 1 PHONE 415. <br /> TSI Trans S Item, htc. (800) 5414213 <br /> MAILING ADD ZESS 416 <br /> 7405 S Hayfe rd RD <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Cheney WA 99004 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 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 - 1 0 1 3 1 7 1 0 1 7 1 3 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and tral legal notifications and mailings to: Z I.FACILITY OWNER ❑ 4.TANK OPERATOR 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISORG DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION, I certif that the inforglottion provided herein is true accurate and in full compliance with legal r uirements. <br /> APPLI NATU DATE 424. 1 PHONE 425. <br /> 41- 12/10/2012 (509) 6234037 <br /> APPLICANT NA ME(prutir 426. I <br /> 1 APPLICANT TITLE T2 <br /> Steven Ray Ticker Regulatory Compliance Manager <br /> UPCF UST-A R4 v.(12/2007) <br />