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OPERAT ERMIT APPLICATION-FACILITY 11PIMATION <br /> KERN COUNTY ENVIRONMENTAL HEALTH SERVICES UNIFIED PROGRAM CONSOLIDATED FORM <br /> DEPARTMENT UNDERGROUND STORAGE TANK <br /> 2700 M STREET,SUITE300 <br /> BAKERSFIELD CA 93301 <br /> (661)862-8700 Fax(661)862-8701 term Page per site) Page 1 of 1 <br /> TYPE OF ACTION ® I.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3 RENEWAL.PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 400' FACILITY ID# 1' <br /> 2 (Agency Use Only) <br /> BUSINESS NAME(Same m FACIUU YNAt.1E or D13A-Doing Business As) 3. <br /> Love's Travel Stop #538 <br /> BUSINESS SITE ADDRESS 103. CITY IN, <br /> 15250 North Thornton Road Lodi <br /> FACILITY TYPE ❑ I.MOTOR VEHICLE FUELING ® 2.FUEL DISTRIBUTION 03. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes M No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407- PHONE 408. <br /> Love's Country Stores of California 405 687-1060 <br /> MAILING ADDRESS 409. <br /> PO Box 26210 <br /> CITY 4M STATE 41 L ZIP CODE 412. <br /> Oklahoma Ci OK 73126 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1 PHONE 428-2 <br /> Love's Country Stores of California (405)687-1060 <br /> MAILING ADDRESS 428.3 <br /> PO Box 26210 <br /> CITY 4254 1 STATE 428-5 ZIP CODE 428-6 <br /> Oklahoma City OK 73126 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415, <br /> Love's Country Stores of California (405)687-1060 <br /> MAILING ADDRESS 416. <br /> PO Box 26210 <br /> CITY 417. 1 STATE 418. ZIP CODE 419. <br /> Oklahoma City OK 73126 <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 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 /> N 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> 4os <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the information provided herein is true,accurate and in full compliance with legal requirements. <br /> I SIGNt\TURE DATE 424. 1 PHONE 425_ <br /> 6/13/2013 (405)687-1060 <br /> A"LICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Kimberly Mills for Love's Country Stores of West Coast Environmental Manager <br /> CA <br /> UPCF UST-A Rev.(122007) <br />