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6) UNIFIED PROGRAM CONSOLIDATED FORM f� 1`1 d UNDERGROUND STORAGE TANK V� L OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. For an UST permanert closure or removal, completeonly this section and Sections 1, Il, III, IV, and IX below) 430 ❑ L 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: 430a I DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) w / T _ O Q _ 6 -7 Z I BUSINESS NAME (Same as FACILITY NAME or DBA -Doing Business As) 3 Flying J Travel Plaza - #618 BUSINESS SITE ADDRESS 103 CITY 104 1501 N. Jack Tone Rd 1 Ripon H. TANK DESCRIPTION TANK ID # 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ISI 1. A STAND-ALONE TANK 4 � -0 67 ❑ 2. ONE IN A COMPARTMENTED UNIT. Complete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 12000 1 M. TANK USE AND CONTENTS TANK USE N 1 a. MOTOR VEHICLE FUELING ❑ lb. MARINA FUELING ❑ 1 c. AVIATION FUELING 439 ❑ 3. CHEMICAL PRODUCT STORAGE ❑ 4. HAZARDOUS WASTE (Includes Used oil) ❑ 5. EMERGENCY GENERATOR FUEL [HSC §25281.5(c)] ❑ 6. OTHER GENERATOR FUEL ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 439a CONTENTS PETROLEUM: N 1 a. REGULAR UNLEADED ❑ 1 c. MIDGRADE UNLEADED ❑ 1 b. PREMIUM UNLEADED 440 ❑ 3. DIESEL ❑ 5. JET FUEL ❑ 6. AVIATION GAS ❑ 8. PETROLEUM BLEND FUEL ❑ 9. OTHER PETROLEUM (Specify): 440e NON -PETROLEUM: ❑ 7. USED OIL ❑ 10. ETHANOL ❑ 11. OTHER NON -PETROLEUM (Specify): 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I. 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 (Specify): 444a SECONDARY CONTAINMENT ❑ 1. STEEL N 3. FIBERGLASS ❑ 6. EXTERIOR MEMBRANE LINER ❑ 7. JACKETED 445 ❑ 90. NONE ❑ 95. UNKNOWN [199. OTHER (S eci 445a 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 ❑ 1. SINGLE -WALLED N 2. DOUBLE -WALLED [199. OTHER 460 SYSTEM TYPE N I. PRESSURE ❑ 2. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑ 4. SAFE SUCTION 123 CCR §2636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ 8. FLEXIBLE ❑ 10. RIGIDPLASTIC 464 ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ I . STEEL N 4. FIBERGLASS ❑ S. FLEXIBLE ❑ 10. RIGID PLASTIC 464b ❑ 90. NONE ❑ 95. UNKNOWN ❑ 99. OTHER (Specify): 464c PIPINGITUR13WE CONTAINMENT SUMP TYPE N 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 90. NONE 464d VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ L STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464e 464el VENT SECONDARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641` 4641`1 VR PRIMARY CONTAROA NT ❑ I. STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4648 464g] VR SECONDARY CONTAINMENT ❑ 1. STEEL N 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 1. SINGLE WALL ❑ 2. DOUBLE WALL N 90. NONE 464{ - RISER PRIMARY CONTAINMENT N L STEEL ❑ 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 4641 464' 1 RISER SECONDARY CONTAINMENT ❑ L STEEL ® 4. FIBERGLASS ❑ 10. RIGID PLASTIC ❑ 90. NONE ❑ 99. OTHER (Specify) 464k 464k1 FILL COMPONENTS INSTALLED N 1. SPILL BUCKET N 3. STRIKER PLATEIBOTTOM PROTECTOR N 4. CONTAINMENT SUMP 45la-c VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE N 1. SINGLE WALL ❑ 2. DOUBLE WALL ❑ 3. NO DISPENSERS ❑ 90. NONE 469a CONSTRUCTION MATERIAL ❑ 1. STEEL N 4. FIBERGLASS ❑ 10. RIGIDPLASTIC ❑ 99. OTHER (Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S) ❑ 4. IMPRESSED CURRENT ® 6. ISOLATION 448' IX. 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 com ]lance with legal requirements. APPLI RE DATE 47°. �- -G U A 1 NTNME print) 471' APPLICANT TITLE 472' Joey Cupp Environment Management UPCF UST -13 - 1/23 Rev. (12/2007)