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Qysf-i d <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 R 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 /> TOTAL NUMBER OF USTs AT FACILITY 404' FACILITY ID# <br /> 5 (Agency Use Only) <br /> BUSINESS NAME(Same as FACn.rN NAMR or DRA-Doing Business As) 3' <br /> Flying J Travel Plaza - #617 <br /> BUSINESS SITE ADDRESS 103. CITY 1°4 <br /> 15237 N. Thornton Rd Lodi <br /> FACILITY TYPE N 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 409. <br /> Pilot Travel Centers, LLC -Joey Cupp 865-474-2826 <br /> MAILING ADDRESS 409. <br /> 5508 Lonas Road <br /> CITY CO. I STATE 411• 1 ZIP CODE 412. <br /> Knoxville TN 37939-0146 <br /> IIF: TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428 1• PHONE 4z8-z <br /> Pilot Travel Centers, LLC 209-827-1399 <br /> MAILING ADDRESS 428.3 <br /> 15237 N. Thornton Rd <br /> CITY 4284 1 STATE 428-5 ZIP CODE 428-6 <br /> Lodi CA 95242 <br /> yIV)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. 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. OARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY TK HQ 44- 7D 1 3 1 6 1 2 1 0 1 7 Call the State Board of Equalization,Fuel Tax Division,if there are questions. 421• <br /> VI.PERMIT HOLDER INFORMATION <br /> 423 <br /> Issue permit and send legal notifications and mailings to: R 1.FACILITY OWNER ❑ 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 /> CERTIF TION: I certif y that the information provided herein is true accurate and in full compliance with legal requirements. <br /> APPLIC <br /> DATE 424• PHONE 425. <br /> .� <br /> 865-474-2826 <br /> L ANT AME(pr' 426• APPLICANT TITLE 4n <br /> Joh Cu Environment Mana ement <br /> UPCF UST-B-1/1 <br />