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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(one conn per USI') TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,H,111,IV,and IX below) 43U ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT M 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE.UST PERMANENTLY CLOSED: 4301 1 DATE EXISTING UST DISCOVERED:8121/2001 4;0b 1. FACILITY INFORMATION FACILITY ID#(Agency Use Only) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busincss As) Love's Travel Stop#223 BUSINESS SITE ADDRESS 103 1 CITY 14 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 page for each com ant in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 20000 1 III.TANK USE AND CONTENTS TANK USE ® 1 a.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑4.HAZARDOUS WASTE(Ioeludes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§252s 1.5(e)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.0rHER (Specify): 439a CONTENTS PETROLEUM: ❑ 1 a.REGULAR UNLEADED ❑ 1 c.MIDGRADE UNLEADED ❑ 1 b.PREMUM UNLEADED 440 ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATTON GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.0711m, PETROLEUM (Specify): up to 5%Biodiesel 440 NON-PETROLEUM:❑ 7.USED OB ❑ 10.ETHANOL ❑ 11.OTIiER NON-PETROLEUM(S i : 440b IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIv1ARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99 OTHER S 444a SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER S 445a OVERFILL PREVENTION ❑ [.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ® 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(1)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(specify): 4640 PIPINGfrURBINE 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 CONTA 04ENT ❑ 1.STEEL ® 4.FIBERGLASS 0 to.RIGID PLASTIC El 90.NONE 99.OTHER(specify) 464a 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ® 90.NONE [199.OTHER(Specify) 464f 4641 VR PRIMARY CONTAINMENT 1.STEEL N 4.FIBERGLASS 10.RIGID PLASTIC E3 90.NONE E3 99.OTHER(Specify) 4646 464 l VR SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC N 90.NONE Ij 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL 19 90.NONE 4641 RISER PRIMARY CONTAINMENT 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC El 90.NONE 99.OTHER(Specify) 4b4i 46x1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ❑ 1.SPILL BUCKET ❑ 3.STRIKER PLATE/BOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 4511-e VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ I.STEEL ❑ 4.FIBERGLASS N 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 44s DL APPLICANT SIGNATURE CERTIFICATION: i rerrlry that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in fall at 'aoce with Imal requirements. APPLICANT SIGNATURE DATE 12/27/2010 470. APPLICANT NAMR(print) Kimberly Mills 471. APPLICANT TITLE Environmental Compliance Analyst 472. UPCF UST-8-1/2 Rev.(12l200'n