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INIFIED PROGRAM CONSOLIDATED FOR,1111 PR#:PROS 16526 4 N u r FAC#:FA0012659 UNDERGROUND STORAGE TANKS -FA ED f /h (one p ftL , TYPE OF ACTION ❑ I.NEW SITE PERMIT 3.RENEWAL PERMIT CI IANGE OF INFORYIATION ❑ 7.PERMANECYS SITrE� (Check one item only) 4.AMENDED PERMIT span[•d ange local use only ❑ S.TANK REl N 2003 03 < �uaarr ❑ G.I IAIPORARY SITE CLOSERE 400 I.FACILITY/SITE INFORMATION MEame 1553 COLONY RD,.RIPON PERNIITSFRwCES BUSINESS NA (Sas FACILrrY NAME or DBA-Doing Business As) 3 FACILITY ID# PR ID# LOVES COUNTRY STORE FA0012659 PR0516526 I I I I I I 1 NEAREST CROSS STREET 401 FACILITY OWNER TYPE ❑ 4.LOCAL AGENCY/DISTRICT- COLONY X L CORPORATION ❑ 5.COUNTY AGENCY* BUSINESS ❑ 2INDIVIDUAL TYPE 1•GAS STATION ❑3.FARM ❑ 5.COMMERCIAL . ❑ 6.STATE AGENCY* ❑ 2.DISTRIBUTOR ❑4.PROCESSOR ❑ 6.OTHER 403 ❑ 3.PARTNERSHIP ❑ 7.FEDERAL AGENCY' 402 TOTAL NUMBER OF TANKS Is facility on Indian Reservation or *If owner of UST is a public agency:name of supervisor of division,section or office which operates REMAINING AT SITE trustlands? the UST(This is the contact person for the tank records.) 404 ❑ Yes ®No 405LOVES COUNTRY STORES OF CA 406 II.PROPERTY OWNER INFORMATION PROPERTY OWNER NAME CA ao7 PH -�� J aoa MAILING OR STREET ADDRESS c/�T•rV� li p9 PO BOX 26210 CITY 4 i o STATE 4t t ZIP CODE 4 , OKLAHOMA CITY OK 73126 PROPERTY OWNER TYPE 1.CORPORATION ❑ 2.INDIVIDUAL ❑4.LOCAL AGENCY/DISTRICT ❑ 6.STATE AGENCY ❑3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY 413 III.TANK OWNER INFORMATION TANK OWNER NAME 414 PHONE 415 LOVES COUNTRY STORE 800 388-0983 MAILING OR STREET ADDRESS 416 PO BOX 26210 CITY 411 STATE q18 ZIP CODE 419 OKLAHOMA CITY OK 73126 TANK OWNER TYPE 1.CORPORATION ❑ 2.INDIVIDUAL ❑ 4.LOCAL AGENCY/DISTRICT 1:16.STATE AGENCY 420 ❑ 3.PARTNERSHIP ❑ 5.COUNTY AGENCY ❑ 7.FEDERAL AGENCY IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER TY(TK)HQ 44- 1 Call(916)322-9669 if questions arise 421 V.PETROLEUM UST FINANCIAL RESPONSIBILITY INDICATE METHOD(s) ❑ 1.SELF-INSURED ❑4.SURETY BOND ❑ 7.STATE FUND ❑ 10.LOCAL GOVT MECHANISM 1:12.GUARANTEE 1:15.LETTER OF CREDIT ❑X 8.STATE FUND&CFO LETTER 1199.OTHER ❑3.INSURANCE 1:16.EXEMPTION ❑ 9.STATE FUND&CD 422 VI.LEGAL NOTIFICATION AND MAILING ADDRESS Check one box to indicate which address should be used for legal notifications and mailing. OF 1•FACILITY ❑2.PROPERTY OWNER X 3.TANK OWNER 423 Legal notifications and mailing will be sent to the tank owner unless box 1 or 2 is checked. VII.APPLICANT SIGNATURE Certification-I certify that the information provided herein is true and accurate to the best of my knowledge. rch, oz-)-U, S ti�.A S a C LC SIGNATURE OF APPLICANT DATE 414 PHONE 425 A Q & ? -/T-D3 0 302-(,,wz NAME OF APPLICANT(print)0 426 TITLE OF APPLICANT 427 t t F'• K •r'�JIA 1r ` U�/.1'�"�y„'44✓�4P /� :V f STATE UST FACILITY NUMBER(For local ue only) 428 1998 UPGRADE CERTIFICATE NUMBER(For local we only) 429 Is 1998 Compliant?Y UPCF(1/99 revised)