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Ml <br /> UNIFIED PROGRAM CONSOLIDATED FORM ►" <br /> UNDERGROUND STORAGE TANK /4L <br /> OPERATING PERMIT APPLICATION—FACILITY INFORMATION <br /> • (One form per facility) 01 <br /> TYPE OF ACTION El1.NEW PERMIT ® 5,CHANGE OF INFORMATION [17.PERMANENT FACILITY CLOSURE 400. <br /> (Check one item only) ❑ 3.RENEWAL PERMIT ❑ 6,TEMPORARY FACILITY CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL.NUMBER OF USTs AT FACILITYFACILITY ID p 11, <br /> p 5 (Agency Use Only) _I <br /> 7 1 <br /> BUSINESS NAME(Sema as FACIUTY NAME or DBA—Doing Business As) <br /> Flyinp,J Travel Plaza-#617 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 15237 N. Thornton Rd Lodi <br /> FACILITY TYPE ® I.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 /> H. PROPERTY OWNER INFORMATION <br /> PROPERTY OWNER NAME 401 PHONE 409 <br /> Pilot Travel Centers, LLC—Joey Cupp 865-474-2826 <br /> MAILING ADDRESS 409 <br /> 5508 Lonas Road <br /> CITY 410 1 STATE 411 ZIP CODE 412 <br /> Knoxville TN 37939-0146 <br /> M. TANK OPERATOR`INFORMATION <br /> TANK OPERATOR NAME 428-1 1 PHONE 428-2 <br /> Pilot Travel Centers, LLC 209-827-1399 <br /> MAILING ADDRESS 428-3 <br /> 15237 N. Thornton Rd 429-5 Z[p CODE 429 6 <br /> CITY 429.4 STATE <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 /> 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 ® 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,ifthere are questions. 421 <br /> VI.PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: ® 1.FACILITY OWNER ❑ 4.TANK OPERATOR <br /> 423 <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required For Public Agencies Only) 406, <br /> VH.APPLICANT SIGNATURE <br /> CERTIMATION.-T/Arfify t the information provided herein is true accurate and in full compliance with legal requirements. <br /> AP A DATE 424 1 PHONE 425, <br /> March 15, 2012 865-474-2826 <br /> �AfPL NT AME(print) 426. APPLICANT TITLE 427 <br /> Joey Cupp Environment Management <br /> UPCF UST-B-1/1 <br />