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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) TYPE.OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,III,IV,and IX below) 430 ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SrM ❑ 8.UST REMOVAL DATE.UST PERMANENTLY CLOSED: 4301 DATE EXISTING UST DISCOVERED:8/21/2001 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) - , BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Love's Travel Stop#223 BUSINESS SITE ADDRESS 103 Crl'Y 104 1553 Colony Road Ripon H.TANK DESCRIPTION TANK ID# 4 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 Modem Welding ®1.A STAND-ALONE TANK ❑ 2.ONE IN A COMPARTMENTED UNIT. Complete one pMe for each cmparmmt in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 20000 1 111.TANK USE AND CONTENTS TANK USE ® 1 a.MOTOR VEHICLE FUELING ❑ I b.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE pachKks Used 00) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25291.5(e)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 439a CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (specify): up to 5%Biodiesel 44N NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4442 SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(S 4451 OVERFILL PREVENTION ❑ 1.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT IN 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED [12.DOUBL&WALLED ❑99.OTHER 460 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(&x3)] 459 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 4642 SECONDARY CONTAINMENT ❑ 1.S IEEL 1@ 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS 0 10.RIGID PLASTIC 0 90.NONE 99.OTHER(Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE 0 99.OTHER(Specify) 4641' 464f1 VR PRIMARY CONTAINMENT 0 I.STEEL 2 4.FIBERGLASS El 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 0DOUBLE WALL ® 90.NONE 4641. RISER PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS 10.RIGID PLASTIC L1 90.NONE 0 99.OTHER(Specify) 464] 464'l RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 0 10.RIGID PLASTIC 19 90.NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONF,NTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTFCTOR ❑ 4.CONTAINMENT Sump 451- VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 9n.NONE 469. CONSTRUCTION MATERIAL. ❑ 1.STEEL ❑ 4.FIBERGLASS ® 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b- VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 448 DL APPLICANT SIGNATURE CERTIFICATION: i certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is tree,accurate, and in full m 'cine with I ulrements APPLICANT S[GNA'I'URE 2 DATE 12/27t2010 470 APPLICANT NAME(print) Kimberly Mills 471. APPLICANT TITLE Environmental Compliance Analyst 472 UPCF UST-B-1/2 Rev.(1212007)