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IED OG CONSOLIDATED <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 0 S.CHANGE OF INFORMATION 7.PERMANENT FACILITY CLOSURE • <br /> (Check one Item only) 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY - d04 FACILITY ID# 1 <br /> (Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3. <br /> Flying J Inc. <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1501 North Jack Ton® Road Ripon <br /> FACILITY TYPE 0 1.MOTOR VEHICLE FUELING 0 2.FUEL DISTRIBUTION 403" Is the facility located on Indian Reservation or 405' <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? 1.Yes 0 2.No <br /> 111. PROPERTY OVYMR INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408. <br /> FJ Properties 0 296-7741 <br /> MAILING ADDRESS 409. <br /> 333 W. Center Street <br /> CITY 410. STATE 411• ZIP CODE 412• <br /> North Salt Lake JUT 84054 <br /> M. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. 1 PHONE 428-2. <br /> J Properties (801) 296-7741 <br /> MAILING ADDRESS 423-3. <br /> 333 W. Center Street <br /> CITY 4294. STATE 5• ZIP CODE 428-6. <br /> North Salt Lake JUT 54 <br /> INFORMATIONIV. TANK OWNER <br /> TANK OWNER NAME 414. PHONE 415. <br /> CFJ Properties (801)296-7741 <br /> MAILING ADDRESS 416. <br /> 333 W. Center Street <br /> CITY 417.ISTATE 418. 1 ZIP CODE 419. <br /> North Salt Lake UT 84054 <br /> OWNER E: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420• <br /> ❑ 7.FEDERAL AGENCY ER 8.NON-GOVERNMENT <br /> EQUALIZATIONV. ]BOARD OF ACCOUNT NUMBER <br /> TY(TK)HQ 44:_1 0 13 12 17 15 7 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421. <br /> .PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: 1.FACILITY OWNER 0 4.TANK OPERATOR 423. <br /> 3.TANK OWNER ❑ S.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406• <br /> VM APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the Infor ation provided herein is ue,accuratt,and in full compliance with legal requirements. <br /> APPLICANT SIGNATURE ' DATE 424. <br /> 5/6/2008 (801) 624-1334 425. <br /> APPLICANT NAME(print) 426• APPLICANT TITLE 427 <br /> Jeff LarsenDirector of Health, Safety, and Environmental <br /> UPCF UST-A Rev.(12/2007).1/2 www.unidocs.org <br />