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UNDERGROUND STORAGE TANK SYSTEM <br />AFFIRMATIVE STATEMENT OF COMPATIBILITY <br />For use by Undoes Member Agencies or where approved by your Local Jurisdiction <br />AuthorityCited: Title 23 California Code of Regulations §2631(j) <br />Unified Program Agency Use Only <br />This document must be completed and submitted to your local UST Program Unified Program Agency prior to storing Biodiesel or E85 in an <br />underground storage tank (UST) system. If you store alternative fuel in more than one UST, you must submit a separate form for each tank. For <br />additional information, refer to the Unidocs Underground Storage Tank System Compatibility With Alternative Fuels available at www.unidocs.org. <br />I. Facility and Tank Information <br />Facility Name: Love's Travel Stop # 223 <br />Site address: 1553 Colony Road <br />Phone No.: (405) 687-1060 <br />city: Ripon <br />ext. <br />BId . No.: <br />Contact Name: Jesse Diaz <br />entail: Jesse. Diaz@loves.com <br />Tank ID #:,-rA 0 S 15 S 4 T Capacity (gal.): �% () y 0 Product Stored: N B20; F1 B 100; D E85, 0 Other (specify) <br />II. Tank System Compatibility <br />The California State Water Resources Control Board (SWRCB) maintains a list of UST system components whose manufacturers have demonstrated <br />compatibility with alternative fuels. The list is available at www.waterboards.ca.gov/water_issues/programs/ust/alt_comp_opt/soc.shtmi. In the <br />table below, provide the requested information for each component. If you unable to check one of the three boxes in the last column for any <br />component, you must apply for a permit from the local UST Program Unified Program Agency and retrofit the tank system with approved <br />components or cease the storage of alternative fuel in the UST system. <br />Manufacturer <br />NameNumber <br />Model or Part <br />Year <br />Manufactured <br />Compatibility With the Specific Product <br />Stored Has Been Demonstrated B <br />Third -party approval (e.g., UL listing) for use with <br />Double -Wall Tank <br />this specific fuel. <br />Modern Welding <br />g <br />Glasssteel <br />2000 <br />❑x ManufacturetsAffirmativeStatement ofCompati- <br />bility posted on SWRCB website. <br />❑ Manufacturer's Affirmative Statement of Compati- <br />bility submitted with this form. <br />Third -party approval (e.g., UL listing) for use with <br />Primary Product Pipe <br />this specific fuel. <br />AO Smith /NOV Fiber Glass Systems <br />y <br />Red Thread <br />2000 <br />FMI M��acttedonSurces ffumative bsiStatementofCompati- <br />bility posted on SWRCB website. <br />❑ Manufacturer's Affirmative Statement of Compati- <br />hilitv.%ubmitted with this form. <br />UN -100 awµ.unidocs.or, 1/4 - 11/16/15 <br />