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OPERATING IT AI'I'LICATION-TANKINFORM N(OneformperUST) KERN COUNTY ENVIRONMENTAL HEAL VICL:S IFIED PROGRAM CONSOLIDATED FORM DEPARTMENT UNDERGROUND STORAGE TANK 2700 M STREET,SUITE 300 BAKERSFIELD,CA 93301 (661)862-8700 Fax(661)862-8701 (one page per tank) Page 1 of 4 TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,IB,IN,and IX below) 430 ® 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.OST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 43011 DATE EXISTING UST DISCOVERED: 43% I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Love's Travel Stop#538 BUSINESS SITE ADDRESS [in I CITY 109 15250 North Thornton Road Lodi D.TANK DESCRIPTION TANK ID# 1 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 Xerxes ® LA STAND-ALONE TANK ❑ 2.ONE IN A COMPARTMENTED UNIT. Inc ane ia,,fish wmpaitiment in the unn. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN TBE UNIT 437 92013 30000 1 III.TANK USE AND CONTENTS TANK USE W Ia.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Io W.Uaed On ❑ 5.EMERGENCY GENERATOR FUEL INK§25281.5(.)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ® la REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 490 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 44011 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS if : 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.MUM Spmify): 444. SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify) 44511 OVERFILL PREVENTION ® 1.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 ®2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 0 L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION In CCR§2636(a)(3)l 458 PRIMARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGIDPLASTTC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTYB3R(Spwify): 464a SECONDARY CONTAINMENT ❑ L STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGIDPLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464. PIPING/TURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 90.NONE 4644 VL VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL W 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 469e1 VENT SECONDARY CONTAINMENT ❑ I STEEL ® 4.FIBERGLASS ❑ HL RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 464Fl VR PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4646 464 1 VR SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464n ab4m VENT PIPING TRANSITION SUMPTYPE ❑ 1.SINGLE WALL 181 2.DOUBLE WALL ❑ 90.NONE 4691 RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spent') 469i 4641 LRAPPLICANTSIGNATURE ONDARY CONTAINMENT ❑ 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 ONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATEIBOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) TION TYPE ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4698 CTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469bc VIII. CORROSION PROTECTION MPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.(SOLA PION 448, IX. APPLICANT SIGNATURE CATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is true,accurate, and in fullm liance with legal requirements.NT SIGNATURE DATE 7/29/2013 470. NT NAME(print) Kimberly MI 471. APPLICANT TITLE West Coast Environmental Manager 472. T-B-12 Rev.(1220111)