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OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per UST) KERN COUNTY ENVIRONMENTAL HEALTH SERVICES UNIF1fiD PROGRAM CONSOLIDATED FORAf DEPARTMENT UNDERGROUND STORAGE TANK 2700 M STREET,SUITE 300 BAKERSFIELD,CA 93301 (661)862-6700 Far(66I)862-8701 (ane page per tank) PaW hof 4 TYPE OF ACTION ((peck one nem only. For UST p=uLn of closure w mwyaL comph:te only this section and Secticm L It,IU,IV,aid LX bdow) ® 1.NEW PERMIT ❑ 3.RFNEWAI.PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430, 1 DATE EXISTING UST DISCOVERED: 43% L FACILITY INFORMATION FACILITY ID X(Agency Use Only) _ 1 BUSINESS NAME(SmSa;is FACILITY NAME or DBA-Doing gnui sAs) (� 1 Love's Travel Stop 19538 r BUSINESS SITE ADDRESS 131 CRY Mol 15250 Nonh7Lominn Road ldli U.TANK DESCRIPTION TANK IDM 3 412 TANK MANUFACTURER 41) TARKCONUGURAIMN:THIS TANK IS 414 XMM [11.A S?AND-ALDNE TANK ®2.ONE IN A COMPARTMENTED lwTi'. rm as u..a� ma.md DATE UST SYSTEM INSTALLED 435 TANK CAPACITY W GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 912013 8000 2 III.TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic AVIATION FUELING 13u ❑ 3.CHEMICAL PRODUCT STORAGE Q 4.IIAZARDOUSWASTE(landu Um OTO ❑ S.EMERGENCY GENERATOR FUEL I3mc42v9si.s(eH ❑ 6.OTIRMGENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.0THER (Specify): 41q CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ Ic.MHX)RADE UNLEADED ® Ib PREMIUM 1 as EADED 440 ❑ 3.D[ESEL ❑ 5.JET BIEL ❑ 6.AVIATION GAS ❑ a.PETROLEUM BLEND NEL ❑ 9-OTHER PfmiotfrUM 4+0. NOWPERtOiEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11 OTHER NON-PFM EUM TICS IV. TANK CONSTRUCTION TYPEOFTANK 01.SINGLE WALL to t.DOUBLE WALL 095.1NKNOWN u3 PALMARY CONTAINMENT ❑ 1.STEEL I@ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 441 ❑ 7.STEEL+•INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.01IIPR k 444, SECONDARYODNTAINMENT ❑ 1.STEEL. ®3.FIBERGLASS 0 6.137CfERIMMEMBRANEL.DIFR ❑ 7.IACKEfID NS O W.NONE ❑ 95.UNKNOWN ❑99 OTHER if : as. OVERFILL PREVENTION 0 I.AUDIBLE A VISUAL ALARMS ❑ 2.BALL FLOAT N 3.FILL TUBE SHUT-OFF VALVE 452 F34.TANK MEETS RB FOR 0CMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION (31.SINGLE-WALLED 1812DOUBLE-WAILED 099.OTHER 439 SYSTEM TYPE N 1,PRESSURE 0 2.ORAVITY 3.CONVeMONALSVCITON L, SAFE SUC770N P3[%R 4w PRIMARY OONTAIN ENT ❑ 1.STEEL IN 1.FIBERGLASS LI8.FLEXIBLE 0 0.RIGID PLASTIC 431 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99. Specify): 43w SECONDARYCONTAINMENT 0 1.STEEL IR I.FMERGLASS U B.FTnVlnlE 0 10.RIGID PLASTIC 4Mb ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S -fy): I344 PIPwCJ(URHwE CONTAINMENT SUMP TYPE ❑ LSINGLE WALL 181 ==WAIL 90 NONE 1313 VL VENT,VAPOR RECOVERY(VR)AND RISER/FELL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAR04ENT 1.STEL 0 4.FIBERGLASS 0 10.RIGIDPIASTIC 90.NONE 99-OTHER(Specify) 434 464e1 VENT SGCOMDARYCONTAINAfE77T I.S'IEt7. 0 4.FIBERGLASS 0 Io.A1GIDF.ASTfC C3 90.NONE ❑ 99.OTHM(SMB%) 434r 164n VR PRIMARY L'ONTATNMEXT 0 1,SIF2:L 0 4.PIBERGLASS Ll WRIGIDPLASITC 0 90.NONE 0 W.OTHER(8pedty) 4wa VR SECONDARY CONTAINMENT U I.STFEI. R 1.FIBERGLASS u 10.RIGIU PIASIIC 13 90.NONE 0 99.OTHER(Specify) Owe wS) VENT PPwO TRANSITION SUMP TYPE 0 I.SINGLE WALL 2.DOUBLEWALL 90.NONE 464i RISER PRIMARY CONTAINMENT Rg 1.STEEL. ❑ 1.FIBERGLASS ❑ 10.RIGm NASIIC HU 90,NOW U 99.OTHER(Specify) 4641 434i RISER SECONDARY CONTAINMENT 0 1.STEE 0 4.FIBERGLASS 13 HI RIGH)PLASTIC E3 90 NONE 0 99.OTHER(SN,*) Owl 64e1 Fll1.CAA4'ONFJ9'[S INSTALLED 11I.sPjLLBucKL1r I.SIRSKEA PIATPIBOTIOM PROTECIUR MALCONTAINMENTsumi, 4s14c VII.UNDER DISPENSER CONTAINMENT(UDC CONSTRUCTION TYPE D 1,SINGLE WALL ® 2.DOUBLE WALL ❑ 3.NO DISPENSERS (3 90.NONE--•-_;Z 439. CONSTRUCTION MATERIAL I.STEEL 19 4.FIBERGLASS El 10.RIGID PLASTIC ❑ 99.OTHER 43FD( VDL CORROSION PROTECTION c=,= STEEL COMPONENT FROTFETION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION IX. APPLICANT SIGNATURE C¢R71RCATiON:I certify that fhb UST"M is compattblt with the haUrdous nbsmnce stared and that the iafarmation provided hcrna aamnte, and to tail tom 11R0ee with 1 ulrements. APPLICANT SIGNATURE DATE /28/2013 "m APP4ICANT NAAIH(print) Kimberly Mill "1L APPLICANT TrnE WestCoast Environmental Wilder UPCF USI-B-V1 Rev.(I V2007)