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OPERATING PERMIT APPLICATION—FACII.TTY INFORMATION <br /> KERN COUNTY ENVUCOMEJU AL HEALTH ShRVIM UNIFIED PROGRAM CONSOLIDATED FORM <br /> DEPARTMENT UNDERGROUND STORAGE TANK <br /> 2700 M STREET,SUTTE 01) <br /> B.4REPSFEW CA 93301 <br /> (MI)9624M Fes(661)862-8701 (ova P^Ge Por Bite) P+Be.L of)_ <br /> TYPE OF ACTION ® 1.NEW PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILITY CLOSURE 4m <br /> (fir anc hern.1y) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> 1. FACILITY INFORMATION <br /> TOTAL.NUMBER OF USTs AT FACILITY 4°4 FACILITY ID A TTT_ [y / 1 <br /> 2 (Agency Un Only) — D (!7 <br /> BUSINESS NAME(s.m,.eAmnr NAME or BW-udoe&maesA,l I" <br /> Love's Travel Stop#538 <br /> BUSINESS SHE ADDRESS m- I COY1w <br /> 15250 North Thornton Road Lodi <br /> FACILITY TYPE. ❑ 1.MOTOR VEH(CIE kUELING ® 2.FUEL DISTRIBUTION �" Is thefeeility loaned on Indian Rewvatkm or <br /> _ 0 3.FARM 0 4.PROCESSOR 0 6.OTHER Trust IwW ❑Yes 21 No <br /> TL PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 4al_ PHONE �- <br /> Love's Country Stores of California 405 687-1060 <br /> MAILING ADDRESS <br /> PO Box 26210 <br /> . CITY 410 STATE 411. ZIP CODE 412 <br /> Oklahoma City OK 73126 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 474-1 PHONE 4n4 <br /> Love's Country Stores of California (405)687-1060 <br /> MAILING ADDRESS 4wa <br /> PO Box 26210 <br /> CITY STATE 4"-5 ZIP CODE + <br /> Oklahoma CitV OK 73126 <br /> I.V. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 414, <br /> Love's Country Stores of California (405)687-1060 <br /> MAILING ADDRESS 41e <br /> PO Box 26210 <br /> CITY 417 1 STATE, 41a. ZIP CODE 419, <br /> Oklahoma City OK 73126 <br /> OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 436 <br /> ❑ 7.FEDERAL.AGENCY ® &NO N-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TIC)HQ 1014101718121 Call the slate Bomd of Equaii=im Fuel Tm Dividom if ft=are questions a1. <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue Perms and send legal notifications and mailings m: ❑ 1.FACILITY OWNER ❑ 4.TANK OPERATOR 411 <br /> N 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION.SECTION.OR OFFICE(Required For Public Agenda Only) 4w <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I that the information provided herein is true,accurate,and in full cum plianm with 1 muinwean. <br /> SFG TURF. DATE. 474 PHONE <br /> AP <br /> 6/13/2013 405 687-1060 -a� <br /> IC NAME(prim) 4m APPLICANT 7TI'LE I <br /> Kimberly Mills for Love's Country Stores of West Coast Environmental Manager � <br /> CA 99 <br /> UPCP UST-A Rev.(122D07) ` 'I <br />