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_ G1 OPERATING PERMIT APPLICATION-TANK INFORMATION(01m form per um KERN COUNTY ENVIRONMENTAL HEALTH SERVICES UNIFIED PROGRAM CONSOLIDATED FORM DEPARTMENT UNDERGROUND STORAGE TANK 2700 M STREET,SUITE 300 BAKERSFIEID,CA 93301 (661)962-6700 1=(661)362$701 (alec page pu tank) Page I aro TYPE OF ACRON (Check one item only. Foran UST pe4mamad closmc or removal,4nmplcte 4mly this Scclion and Scctioml,ll,IU,IV,and IX below) 4m ® 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION QTEMPORARYUST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SETH &UST REMOVAL DATE UST PERMANENTLY CLOSM. ' I DATE EMSTINO UST DISCOVERED: 4wM L FACILITYINFORMATION FACILITY ED#(4smy Use Onfy) _ BUSINESS NAME(Satnc w FACILITY NAME or DBA-Doing Business AS) I Love's Travel Stop#538 FROlJ BUSINESS SITE ADDRESS Iw C(Ty )w 15250 Nonh Thoroton Road Lodi IL TANK DESCRIPTION TANKED# 2 4n TANK MANUFACTURER 433 TANK CONEGURATIGN:THIS TANK IS 45" ^ Xares ❑I.A STANO-A14NETANR 4% ®2.ONE iN A cowARTmEhisD UNIT. fm raNcom iv a4v amt DATE UST SYSTEM TALLED "35 TANK CAPACITY IN GALLONS 4)6NUMBER OF COMPARTMENTS TN THE UNIT 457 92013 12000 1 LII.TANK USE AND CONTENTS TANK USE ® to MOTORVEFBCI.EFUELM ❑ Ib.MARINA FUELING ❑ 1a AVIATION FUELING 09 ❑ 3.CIE.MOCAI.MODUCTSTORAGE E3 4.HAZARDOUS WASTE(1Aml U4 WI ❑ S.EMERGENCY GIIISRATOR FUELEnw real s(-)) ❑6.OTHER GENEPATORFUEL ❑95.UNU40WN ❑ 99-CMM ): u9. CONTENB PETROLEUM: ❑ L.REGULAR UNLEADED ❑ I.MIDGGRADEUNLEADFD ❑ lb.PRGMIUMUNI.PSDED 449 N 3_E)WSE]. ❑ 5.JET FUMY ❑ 6.AVIATION GAS ❑ B.PEIRDImum BIF Puet. N 9.DOER PETROLEUM Up to5%Biodie l 4+644. NON-PETRA)LEUM:❑7.USED OD. 0T.FTNANOI. ❑ 11.O7.M NON-PETROLEUM ' ): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLEWALL ®2.DOURI.EWALL ❑ 95.UNKNOWN 4n PRIMARY CONTADDAENr ❑ 1.STEEL N 3-FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL.+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444. SECONDARY CVNTAINMFNT ❑ 1.STEEL N 3.FTSFRGIASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7,JACKETED 445 0 90.NONE ❑ 95.UWOJOWN ❑99.OTHER 445. OVERF'B,LPREVENTION 0 I.AUDIBLE R VISUAL ALARMS ❑ 2.BALL FLOAT ® 3,FILE.TUBE SHUT-OFF VALVE 452. ❑ A.TANK MEETS REQUIRE)ADIT5 FOR WDI MPITON FROM OVER FI L PREVEIMON EQUIPMENT V. PRODUCT f WASTE PIPING CONSTRUCTION PIPINGCONSTRUCfION ❑I.SING E-WALLED N 2 DOUBLE-WALLED ❑W9 Gn1FR 4es SYSTEM TYPE N 1.PRESSURE O 2.GRAVITY ❑ 3.CONVENnONALSUCRON 4.SAEESUCIION cal ss . 4511 PRLMARYCONTAINMENT ❑ T.STEEL N 4.E7BERGLASS ❑ 9,FLEXIBLE ❑ IO.RIOMPIA.STIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTNER(Spe6fy): 454, SBCONDARYCONTA1NMilNT D L STEEL N 4.FIBERGLASS ❑ S.FLEXR ll 0 10.REGID PLASTIC 454b ❑ 90.NONE ❑95.UNKNOWN ❑ 99.OTHER 5 ifY: 460.: PMG/rURBlW CONTAINMENT SUMP TYPE ❑ LSINGTF-WALL NZ.DOUBLE WALL 090.NOW 4544 VT.VENT,VAPOR RECOVERY(VR)AND RISER I FILL PIPE PIPING CONSTRUCTION VENTPRIMARYCONTABAdENT U I.STEEL N 4,FIBERGLASS E3 IO.RIGIDPLASTIC 0 9O.NOW n W.OTHER(Specify) 464- 464-1 VENT SECONDARY CONTAMNENI' 0 1.STEEL 19 4.FIBERGLASS 0I0.RIG1D 7'1h5IIC ❑ 90.NONE 0 99,OTHER(Spedfy) 4wr Own VR PAIdARYC'ONTANMENT 1.STEEL la 4.FIBERGLASS 10.RIGID PLASTIC El 90.NONE LI 99.OTWR(Sp®fy) 4ws 49.1 VR SECONDARY CONTAINMENT I.STEN. 0 4.FIBERGLASS 0 l O.IUGID mmuc ❑90.NOW 0 99.OTHER(Spedfy) 46th 444M VENT PIPING TRANSITION SUMP TYPE 171 I:SITGLE WALL IDOUBLE WALL. 0 90.NOW 4wi RLSERPRAMARYCONT� N I.SIEF2. ❑ 4.EBE3IGLASS ❑ ID.RIGB)PLA.SnD El 90.WONE ❑ 99.OTHER ISpx*1 461 1 RISER SECO14DARY CONTAINMENT 0 1.SIM 4.neRAGLASS IO.RIUIDPLASTIC 99 90.NONE LI 99.01DIER(Sprdfy) 4&k 4wkl FR1.0061POTTEN1S D45TA[lED 0 1 SPILI.BUCKET 0 3.BLAMER PIATFiBO'1"[Otd PROTP.CfOR 19 4.COMAPNAEN7'SOtdP 45I.c VIL UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ t.SBNGLEWALL W 2.DOABLE WALT. ❑ 3.NO DISPENSERS ❑ 90.NONE 460. CONSTRUCTION MATERIAL Cl L.STEEL N 4.KgMGLASS 10.RIGm PLASTIC Ll 99.OTSTR(. Ty) =4. 469bc VITT. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CI IRR ENT N 6.ISOLATION M6 IX. APPLICANT SIGNATURE C= CERTIFICATION: I cerdry that this US-F symcm II com(utib(e aith the hmrdow Substance a(ured Sad That the inronoatlm provldcd herein V c"mFZ Set!fu fuB<om iau<c with 1 riremmh. APPLICAanNTSIGNA'St! - DATE 7/28/2013 4m. APPLICANT NAME*int) Kimberly 'I'' APPLICANT TITLE West Coast Environmental Mana a 'n UPCF USr-B-1/2 Rev.(122007)