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OPERATING IT APPLICATION-TANK INFORM N(one form per UST) KERN COUNTY ENVIRONMENTAL HEAL _ VICES IFIED PROGRAM CONSOLIDATED FORM DEPARTMENT UNDERGROUNDSTORAGETANK 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 1,ll,III,N,and IX below) 430 ® 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 93Oe 1 DATE EXISTING UST DISCOVERED: 430b L 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 103 CITY 104 15250 North Thomtou Road Ladi U.TANK DESCRIPTION TANK ID# 2 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 XMes ❑1.A STAND-ALONE TANK ®2.ONE M A COMPARTMENTED UNIT. Co Ift mm fm each cum in the emit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY W GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 432 92013 12000 2 III.TANK USE AND CONTENTS TANK USE N la MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(wd.Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(,)] ❑ &OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4390 CONTENTS PETROLEUM: ❑ la REGULAR UNLEADED ❑ le.MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 4d0 N 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL N 9.OTHER PETROLEUM (Specify): Up to 5%B[odlesel 44oa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER S ib): 444+ SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 445. OVERFILL PREVENTION N 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT N 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED N 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE N 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.X3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ ]0.RIGIDPLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 46a SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99 OTHER(Specify): 464c PIPINGfrURBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL D9 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 468 4681 VENT SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464f 4647 VR PRIMARY CONTAINMENT 0 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 468 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mh `iMh1 VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL N 2.DOUBLE WALL ❑ 90.NONE 464i. RISER PRIMARY CONTAINMENT N 1.SITE[- ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4 i 464'1 RISER SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC N 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED N 1.SPILL BUCKET N 3.STRIKER PLATEBOTTOM PROTECTOR N 4.CONTAINMENT SUMP 451. VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL N 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469+ CONSTRUCTION MATERIAL ❑ L STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 4696, VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT R 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 true,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE - DATE 7/29/2013 470. APPLICANT NAME(print) Kimberly I s 071' APPLICANT TITLE West Coast Environmental Manager 072. UPCF UST-B-12 Rev.(122007)