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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 ACT ON ❑ I.NEW PERMIT ❑ 5.CHANGEOF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400 <br /> (Check one itemonly) ® 3.RENEWAL.PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> 101 AL N UME ER OF USTs AT FACILITY 404, FACILITY ID# 1. <br /> ONE (Agency Use Only) <br /> BUSINESS NAS E(Same as Facility Name or DBA-Doing Business As) 3. <br /> TSI Trans System, Inc. <br /> BUSINESS SITE ADDRESS 103. CITY 104, <br /> 707 E Roth RD. French Camp <br /> FACILITYTYPP: Z 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403" Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.0171F.R Trust lands? ❑ L Yes Z 2.No <br /> U. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407, PHONE 408. <br /> TSI TraniSystem, Inc. (800) 541-4213 <br /> MAILING AD RESS 409. <br /> 7405 S H yford Rd/ <br /> CITY ' 410. 1 STATE 411. ZIP CODE 412. <br /> Cheney Wa 99004 <br /> III. TANK OPERATOR INFORMATION <br /> TANKOPER ORNAME 428-1. PHONE 428-2. <br /> TSI Tran -System, Inc (800) 541-4213 <br /> MAILING ADDRESS RESS 428x. <br /> 7405 S Hayford RD. <br /> CITY 4284. STATE 428-5. ZIP CODE 428 . <br /> Cheney WA 99004 <br /> IV. TANK OWNER INFORMATION <br /> TANKOWNE NAME 414. PHONE 415. <br /> TSI Trans System, Inc. (800) 541-4213 <br /> MAILING ADDRESS 416. <br /> 7405 S Hayford Rd. <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Cheney WA 99004 <br /> OWNER TYPE, ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420 <br /> ❑ TFEDERALAGENCY Z 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK) HQ 44- 1013171017131 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421, <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue Permit an send legal notifications and mailings to: Z I.FACILITY OWNER ❑ 4.TANK OPERATOR 423_ <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR X DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII. APPLICANT SIGNATURE <br /> CERTIFIC ION: I certff at the information provided herein is true,accurate and in full compliance with legal requirements. <br /> APP ANT AT E DATE 424. PHONE 425. <br /> 12/7/2011 (509) 623-4037 <br /> APPLICANT N (print) 426. 1 APPLICANTTITLE an <br /> Steven R iy Tucker Regulatory Compliance Manager <br /> UPCF UST-A I tev.(12/2007)-1/2 www.unidocs.org <br />