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UNDERGROUND STORAGE TANK SYSTEM <br />AFFIRMATIVE STATEMENT OF COMPATIBILITY <br />For use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br />Authority Cited: Title 23 California Code of Regulations §26316) <br />Unified Progranr 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 />eat. <br />Bldg. No.: <br />Contact Name: Jesse Diaz <br />email: Jesse. Diaz@loves.com <br />Tank ID #: —T -A t,5 i S 5 ti 9 -T SCapacity (gal.): �),C) I () C) 0 Product Stored: 0 B20; ❑ B100; ❑ E85; ❑ Other (specify) <br />H. 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.shtml. 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 />Name <br />Model or Part <br />Number <br />Year <br />Manufactured <br />Compatibility With the Specific Product <br />Stored Has Been Demonstrated B <br />❑ Ibird-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 />Manufacturer'sAffumativeStatement ofCompati- <br />bility posted on SWRCB website. <br />❑ Manufacturer's Affirmative Statement of Compati- <br />bility submitted with this form. <br />Third-partyapproval (e.g., UL listing) for use with <br />Primary Product Pipe <br />s s <br />AO Smith /NOV Fiber Glass Systems <br />y <br />Red Thread <br />2000 <br />O MlitypotedonSurees RC13 eStitementofCompati- <br />bility posted on SWRCB website. <br />❑ Manufacturer's Affirmative Statement of Compati- <br />bili submitted with this form. <br />UN -100 www.unidocs.org 1/4 - 11/16/15 <br />