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i <br /> DIED PROGRAM CONSOLIDATED <br /> F UNDERGROUND STORAGE TANK qW <br /> OPERATING,TRMIT APPLICATION-FACILITY INFORMATION <br /> (Ont form per facility) <br /> TYPE OF ACTION ❑ 1.NEW PERMIT 5.CHANGE OF INFORMATION ❑ 7.PERMANENT FACILfI"Y CLOSURE 400. <br /> (Check one item only) ❑ 3 RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY, <br /> INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404. FACILITY ID ll _ t <br /> i <br /> '7 (Agency Use Only) <br /> BUSINESS NAME(Same as FACnrrY 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 ® 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 ®No <br /> II PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 407• PHONE 405. <br /> Pilot Travel Centers, LLC -Joey Cupp 865-474-2826 <br /> 409. <br /> MAILING ADDRESS <br /> 5508 Lonas Road <br /> CITY 410 STATE 411• ZIP CODE 412. <br /> Knoxville TN 37939-0146 <br /> TANK.OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1• PHONE 428-2 <br /> Pilot Travel Centers, LLC 209-599-4141 <br /> 428-3 <br /> MAILING ADDRESS <br /> 1501 N. Jack Tone Rd <br /> CITY 428 a STATE 428-5 ZIP CODE 429-6 <br /> Ripon CA 95366 <br /> IV.;;TANK.OWNEKINFORMATION <br /> TANK OWNER NAME 414. PHONE 415. <br /> Pilot Travel Centers, LLC -Joey Cupp 865-474-2826 <br /> 416. <br /> MAILING ADDRESS <br /> 5508 Lonas Road <br /> CITY 417. 1 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 N 8.NON-GOVERNMENT <br /> V.'BOARD OF.EQUALIZATION UST STORAGE FEE-ACCOUNT NUMBER <br /> TY TK HQ 44- 01 3 1 6 1 2. 10 1 7 1 Call the State Board of Equalization,Fuel Tax Division,if there ar;.questions. 421• <br /> VI`.-PERMIT HOLDER INFORMATION <br /> ' 427 <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER El 4,TANK OPERATOR <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 certif hat the information provided herein is true accurate,and in full compliance with legal requirements. <br /> APPLI I DATE 424• PHONE 425. <br /> 865-474-28?66 <br /> AP T NAME(print' 426• APPLICANT TITLE - 427 <br /> oe Cu Environment Management <br /> UPCF UST-B-1/1 41�1 <br />