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(?T <br />Ah IAIJ aglq 10 <br />UNIFIED PROGRAM CONSOLIDATED FORM% l 07✓/� <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 ❑ 6. TEMPORARY FACILITY CLOSURE ❑ 9. TRANSFER PERMIT <br />I. FACILITY INFORMATION ' <br />40q' <br />TOTAL NUMBER OF USTs AT FACILITYFACILITY <br />ID q <br />_l <br />Olt) <br />U <br />1-16 <br />6 <br />171 <br />-LI <br />7 <br />(Agency Use Only) <br />BUSINESS NAME (Same as FACILITY NAME or DBA - Doing Business As) 3, <br />Flying J Travel Plaza - #618 <br />BUSINESS SITE ADDRESS 103. <br />CITY 104. <br />1501 N. Jack Tone Rd <br />Ripon <br />FACILITY TYPE ® 1. MOTOR VEHICLE FUELING ❑ 2. FUEL DISTRIBUTION 403' <br />Is the facility located on Indim Reservation or 405. <br />❑ 3. FARM ❑ 4. PROCESSOR ❑ 6. OTHER <br />Trust lands? ❑ Yes ®No <br />II. PROPERTY OWNER INFORMATION <br />PROPERTY OWNER NAME 407• <br />PHONE 409. <br />Pilot Travel Centers, LLC - Joey Cupp <br />865-474-2826 <br />MAILING ADDRESS 4W <br />5508 Lonas Road <br />CITY 410. <br />STATE 411. <br />ZIP CODE 412. <br />Knoxville 1 <br />TN <br />37939-0146 <br />M. TANK OPERATOR INFORMATION <br />TANK OPERATOR NAME 428-1. <br />PHONE 428-2 <br />Pilot Travel Centers, LLC <br />209-599-4141 <br />MAILING ADDRESS 429.3 <br />1501 N. Jack Tone Rd <br />CITY 428.4 <br />STATE 429-5 <br />ZIP CODE 429-6 <br />Ripon 1 <br />CA <br />95366 <br />IV. TANK OWNER INFORMATION <br />TANK OWNER NAME 414. <br />PHONE 415. <br />Pilot Travel Centers, LLC - Joey Cupp <br />865-474-2826 <br />MAILING ADDRESS 416. <br />5508 Lonas Road <br />CITY 417. <br />STATE 419. <br />ZIP CODE 419. <br />Knoxville JTN <br />37939-0146 <br />OWNER TYPE: ❑ 4. LOCAL AGENCYIDISTRICT ❑ 5. COUNTY AGENCY ❑ 6. STATE AGENCY 420. <br />❑ 7. FEDERAL AGENCY ® 8. NON-GOVERNMENT <br />V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br />TY (TK) HQ 44- 1 0 1 3 1 6 1 2 1 0 1 7 1 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 information provided herein is true accurate and in full compliance with legal requirements. <br />APP AT <br />D 424. <br />1 PHONE 425. <br />"l Q <br />865-474-2826 <br />09 iCA AME ri 426• <br />APPLICANT TITLE 427 <br />�Joey Cupp <br />Environment Management <br />UPCF UST -13 - 1/1 <br />