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OPERATING PERMIT APP WCATION—FACILITY INFORMATION M 1 <br /> RBRNCOLNIYENVMONMDUALHEALTUSbRVICFS UNIFIED PROGRAM CONSOLIDATED FORM lx /�11 <br /> DEPARTMENT UNDERGROUND WORAGE TANK <br /> 27001d STREET,SURE 3W <br /> BAKFRSFIELD CA 93301 <br /> (661)66 DO F3.(661)861-8701 (aeapngepersue) P✓geLof)_ <br /> TYPF.OFAGTION N LNEW PERMIT ❑ S.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE <br /> (C1icck anc hm only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILrrY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION FI'DO 218 f(.p <br /> TOTAL NUMBER OF USTs AT FACILITY <br /> 404 FACILITY ID d TF -1 1_ _1 1 <br /> 2 (Age-7 Use Only) I ZJ <br /> RUSINFSSNAME(s ..FAm.¢y1u•A .rc -Dansm cew d 3. <br /> Love's Travel Stop#538 R <br /> BUSINESS SITE ADDRESS 1m I ULIY1w <br /> 15250 North Thornton Road Lodi <br /> FAcumYTYPE ❑ f.MOTORVEmcLEFUELNG 2 FUEL DisnunuTfoN 407' Is Die facility located on Indian Reservation m ' <br /> _ ❑ 3.FARM 0 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑Yes R No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME a7. PHONE ws. <br /> Love's Country Stores of California 405 687-1060 <br /> MATLRiO ADDRESS +a9. <br /> PO Box 26210 <br /> CITY 410. STATE 411• 1 ZE'CODE. u2 <br /> Oklahoma City I OK 73126• <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME PHONE +2a3 <br /> Love's Country Stores of California (405)687-1060 <br /> MAILING ADDRESS n�a <br /> PO Box 26210 <br /> CITY 40%+ 1 STATE 4m-6 ZIP CODE ttas <br /> Oklahoma City OK 73126 _ <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNFR NAME 414. PHONE 411, <br /> Love'sCoun Stores of California (405) 687-1060 <br /> MAILING ADDR E55 ala. <br /> PO Box 26210 <br /> CITY 411, 1 STATR ale. ZIPCODE 419. <br /> Oklahoma C' OK 73126 <br /> OWNER TYPE ❑ 4.LOCAL AGENCYIDISTRICT ❑ S.COUNTY AGENCY ❑ 6.STATE AGENCY 4io <br /> ❑ 7.FEDERAL AGENCY ® &NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(ITC)HQ 44- 10 4 0 7 8 2 Call the State Board of F.gaelimaioq Fuel Tu Divisim iflhe.e are questions. 421 <br /> VL PERMIT HOLDER INFORMATION <br /> Ism P=h and send legal notifications and mailinge to: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 4u <br /> — <br /> N 3-TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION.OR OFFICE(Required Fm Public Agencies Only) 406 <br /> VII.APPLICANT SIGNATURE <br /> CERT'IFICATTON: I c 6 that the infurmatioa provided herein is true,accurate,and in Poll tom li"m with legal requirements. <br /> 1 'SIGNATURE DATE. I- I PHONE <br /> 6/13/2013 405 687-1060 <br /> IC NAMF_(prid) 4d'i. APPLICANTTTTLki -+%! <br /> Kimberly Mills for Love's Country Stores of West Coast Environmental Manager f'i+` <br /> CA <br /> UPCF UST-A Rev-(1211007) <br /> i <br />