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UNIFIED PROGRAM CONSOLIDATED FO <br /> • UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION - FACILITY liNFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION ❑ 1.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 41' 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 Tone Road Ripon <br /> FACILITY TYPE ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 403. Is the facility located on Indian Reservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ 1.Yes ® 2.No <br /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408• <br /> CFJ Properties 801 296-7741 <br /> MAILING ADDRESS 409' <br /> 333 W. Center Street <br /> CITY 410. 1 STATE 411. ZIP CODE 412 <br /> North Salt Lake UT 84054 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1. PHONE 428-2. <br /> CFJ Properties (801) 296-7741 <br /> MAILING ADDRESS 428-3. <br /> 333 W. Center Street <br /> CITY 428-4. 1 STATE 428-5. ZIP CODE 428-6. <br /> North Salt Lake UT 84054 <br /> IV. TANK OWNER INFORMATION <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. 1 STATE 418. ZIP CODE 419. <br /> North Salt Lake UT 84054 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY azo. <br /> ❑ 7.FEDERAL AGENCY ® 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44- 1013121715171 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 /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 406. <br /> VII.APPLICANT SIGNATURE <br /> CERTIFICATION: I certify that the infor ation provided herein is t ue,accurate,and in full compliance with le al requirements. <br /> APPLICANT SIGNATURE n ��1 DATE aza. 1 PHONE azs. <br /> 5/6/2008 (801) 624-1334 <br /> APPLICANT NAME(print) 426. APPLICANT TITLE 427 <br /> Jeff Larsen Director of Health, Safety, and Environmental <br /> UPCF UST-A Rev.(12/2007)-1/2 www.unidocs.org <br />