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OPERATING MIT APPLICATION-TANK I N FORM(one form per UST) KERN COUNTY ENVIRONMENTAL HEAL VICES IED 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 1,II,III,IN,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: 430. DATE EXISTING UST DISCOVERED: 430b L FACILITY INFORMATION FACILITY ID p(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 IN 15250 North Thornton Road Lodi IL TANK DESCRIPTION TANK ID 4 3 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 Xerxes ❑L A STAND-ALONE TANK ®2.ONE IN A COMPARTMENTED UNIT. CoWide one Mefor each mm Menem in the wit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 92013 8000 2 Ill.TANK USE AND CONTENTS TANK USE 0 la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Mcmdes Ua 0i0 ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25231.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ❑ ]a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED 0 It.PREMIUM UNLEADED 610 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4I0e NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 44ob IV. TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 0 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CONTAINMENT ❑ 1.STEEL 0 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Specify): 4458 OVERFILL PREVENTION N 1.AUDIBLE@ VISUAL ALARMS ❑ 2.BALLFLOAT ® 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 0 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(e)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464e SECONDARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ I0.RIGIDPLASTIC 4Mb ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPINGn URBINE CONTAINMENT SUMP TYPE ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4Mf 464n VR PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4645 464 1 VR SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE 0 99 OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 0 2.DOUBLE WALL 0 90.NONE 4641 RISER PRIMARY CONTAINMENT ® L STEEL ❑ 4.FIBERGLASS ❑ ]0.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464j 464'1 RISER SECONDARY CONTAINMENT ❑ L STEEL ❑ 4.FIBERGLASS 10.RIGIDPLASTIC El 90,NONE 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET 0 3.STRIKER PLATUBOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451. VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469e CONSTRUCTION MATERIAL ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTHER(Specify) 469b VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 408 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. APPLICANTNAME(prim) Kimberly Mill 411. APPLICANT TTTLE West Coast Environmental Manager 4T2. UPCF UST-B-12 Rev.(1=007)