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N <br /> ,1b atA - <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 40a <br /> (Check one itom only) ❑ 3.RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> L FACILITY INFORMATION <br /> TOTAL NUMBER OF USTs AT FACILITY 404, FACILITY ID# _ 1' <br /> 5 (Agency Use Onty) <br /> BUSINESS NAME(Sam as FACILITY NAME or DBA-Doing Busineu As) 7 <br /> Fl in J Travel Plaza-#617 <br /> BUSINESS SITE ADDRESS 103. CITY 104 <br /> 15237 N. Thornton Rd Lodi <br /> FACILITY TYPF. ® 1.MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION 402. 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 409 <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 423-1. PHONE 428.2 <br /> Pilot Travel Centers,LLC 209-827-1399 <br /> MAILING ADDRESS 428-3 <br /> 15237 N.Thornton Rd <br /> CITY 428.4 STATE 479-5 ZIP CODE 428.6 <br /> Lodi CA 95242 <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME 414, PHONE 415. <br /> Pilot Travel Centers,LLC-Joey Cupp 865-474-2826 <br /> MAILING ADDRESS 416.. <br /> 5508 Lonas Road <br /> Crl'Y 417, STATE 413. ZIP CODE 419, <br /> Knoxville I TN 37939-0146 <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT ❑ 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 J Call the State Board of Equalization,Fuel Tax Division,ifthere are questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® I.FACILITY OWNER El4.TANK OPERATOR 427 <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 /> CERTIFWATI0N_;-Verflfy tD2nhe information provided herein is true securate and In full com fiance with 1tP1 uirements. <br /> APDATE i24. PHONE 425. <br /> 4 rwzv:�z March 15,2012 865-474-2826 <br /> PL N AME(print) 426. APPLICANT TITLE <br /> i <br /> Joey Cupp Environment Management <br /> UPCFUST-B-I/] ^,r' <br />