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N161to ® 1 <br /> ,� µN <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <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 <br /> ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 41. FACILITY ID# _ _ t <br /> 7 (Agency Use Only) <br /> BUSINESS NAME(same as FACn]TY NAME or DBA-Doing Business As) 3 <br /> Flying J Travel Plaza -#618 <br /> BUSINESS SITE ADDRESS 103. CITY 104. <br /> 1501 N. Jack Tone Rd Ripon <br /> FACILITY TYPE E 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? ❑Yes E No <br /> II. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 408. <br /> Pilot Travel Centers, LLC-Joey Cupp 865-474-2826 <br /> MAILING ADDRESS 409. <br /> 5508 Lonas Road <br /> CITY 410. STATE 411• ZIP CODE 412. <br /> Knoxville TN 37939-0146 <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1• PHONE 428-2 <br /> Pilot Travel Centers, LLC 209-599-4141 <br /> MAILING ADDRESS 428-3 <br /> 1501 N. Jack Tone Rd <br /> CITY 4284 1 STATE 428-5 ZIP CODE 428-6 <br /> Ripon CA 95366 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Pilot Travel Centers, LLC-Joey Cupp 865-474-2826 <br /> MAUING ADDRESS 416. <br /> 5508 Lonas Road <br /> CITY 417. STATE 418. ZIP CODE 419. <br /> Knoxville TN 37939-0146 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 5.COUNTY AGENCY ❑ 6.STATE AGENCY 420. <br /> ❑ 7.FEDERAL AGENCY E 8.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 1 O 1 3 1 6 1 2 1 0 1 7 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: E 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 information provided herein is true accurate and in full compliance with legal re uirements. <br /> APPLICANT DAT424. PHONE 425• <br /> 7' 865-474-2826 <br /> (print) 426. APPLICANT TITLE 427 <br /> Jbey CuppEnvironment Management <br /> UPCF UST-B-1/1 <br />