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UPCF UST -B Rev. (12/2007) - 1/2 www.uiiidm.org <br />UNIFIED PROGRAM CONSOLIDATED FORM <br />UNDERGROUND STORAGE TANK <br />OPERATING PERMIT AP'P'LICATION - TANK INFORMATION (One fonn per UST) <br />TYPE OF ACTION (Check- one item only. For a mrctostire or removal, complete only" this Section and Sections 1, 11, 111, If and IX below) <br />0 1. NEW PERMIT <br />430. <br />0 3. RENEWAL PERMIT <br />❑ 0 5. CHANGE OF INFORMATION <br />6. TEMPORARY UST CLOSURE _. Q 7. UST PERMANENT CLOSURE ON SITE 0 8. UST REMOVAL <br />DATE UST PERMANENTLY CLOSED: 430a, I DATE EXISTING UST DISCOVERED: <br />430b. <br />I. FACILITY INFORMATION <br />FACILITY ID # (Agency Use Only) <br />BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) <br />FLYING J TRAVEL PLAZA <br />BUSINESS SITE ADDRESS 103, CITY <br />1501 NORTH JACK TONE ROAD RIPON <br />104. <br />T1. TANK DESCRIPTION <br />TANK ID # 431, 7'p,NKMANUFACTURER 433- TANK CONFIGURATION: THIS TANK IS <br />-4-34. <br />OWENS CORNING 1.A STAND-ALONE TANK compicte one page rar cwh <br />DATE UST SYSTEM❑ 2.ONEINA COMPARTMENTED UNIT comwmcminthe tuth, <br />LLED 435, TANK CAPACITY IN GALLONS 436. <br />NUMBER NUMBER OF COMPARTMENTS IN THE UNIT <br />12/1994 <br />437. <br />....20,000 <br />IR. TANK USE AND CONTENTS <br />TANK USE In. MOTOR VEHICLE FUELING 0 111. MARINA FUELING [I 1c. AVIATION FUELING 439. <br />El 3. CHEMICAL PRODUCT STORAGE 04. HA"ARDOUS WASTE <br />(Includes Used oil) 0 5. EMERGENCY GENERATOR FUEL [HSC 12528 <br />0 &OTHER GENERATOR FUEL Ij 95. UNKNOWN D 99. OTHER (Specify): <br />1.5(c)) <br />439jL <br />CONTENTS PETROLEUM: ff )a.REGULARUNLEADED 13 lc.MID-GRADEUNLEADED El 1b. PREMIUM UNLEADED <br />440. <br />0 3. DIESEL 0 5. JET FUEL El 6. AVIATION GAS <br />0 8. PETROLEUM BLEND FUEL El 9. OTHER PETROLEUM (Specify): <br />_7_OIL <br />NON -P TiBLEUR, 0 440a. <br />USED _--0 I0. ETHANOL <br />11 11. OTHER NON -PETROLEUM (S ecify); 4401: <br />IVANK <br />- TCONSTRUCTION <br />WALL TYPE OF TANK 0 16 SINGLE W N 2. DOUBLE WALL 95. UNKNOWN <br />PRIMARY CONTAINMENT -0 '. STEEL <br />443. <br />6. INTERNAL LADDER <br />IN B <br />El 7. STEEL + INTERNAL LINING Ej 95. UNKNOWN E] 99.OTHER 444a. <br />SEC5NDTl� iTlffOt CONTAINMENT- STEEL �F181i6UES-­ <br />444. <br />U 6. EXTERIOR MEMBRANE LINER El 7. JACKETED <br />Q 90. NONE 0 95. UNKNOWN 0 99. OTHER (Specify): <br />445. <br />445a, <br />OVERFILL PREVENTION 97. AUDIBLE &; VISUAL ALARMS ffj BAILFLOATC9 3. FILL TUBE SHUT-OFF�VALvE <br />0 4,TANK MEETS REqUIRE-MEN1 S FOR EXEMPTION FROM OVERFILL PRPV-TiON EQUIPMENT <br />V. PRODUCT / WASTE PIPING CONSTRUCTION <br />PIPING NS <br />G C UCTIO <br />FPIPING CONSTRUCTION Q 1, SINGLE -WALL N 2. DOUBLE WA!�. 0 99. OTH <br />OUBLE L <br />SYSTEM <br />SYSTEM TYPE�02. GRAVITY ❑ 3. CONVENTIONAL SUCTION ❑0 4. SAFE SU <br />PRIMARY CONTAINMENT SUCTION 123 CCR fi2W3_M­sX3�j__ <br />C U 1. STEEL 0 4. FIBERGLASS <br />460. <br />4-58. <br />❑ &FLEXIBLE ff 0. RIGID PLASTIC <br />0 r 90. NONE - 0 95. UNKNOWN El 99. OTHER (Specify): <br />46k <br />464c, <br />SECONDARY CONTAINMENT 0 I:STEEL0 4. FIBERGLASS 0 8. FLEXIBLE 0 10, RIGID PLASTIC _ <br />464b. <br />11 90. NONE 0 95. UNKNOWN 0 99. OTHER (Specify): 464c. <br />PIPING/TURBINE CONTAINMENT SUMP TYPE A! I. SINGLE WALL 0 2. DOUBLE WALL <br />0 90. NONE <br />VI. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION <br />VENT PRIMARY CONTAINMENT El 1. STEEL N 4, FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE 0 99. OTHER (Specify): <br />464c. <br />VENT SECONDARY CONTAINMENT [3 1. STEE _464SI <br />U I STEEL E9 4. FIBERGLASS 0 10. RIGID PLASTIC 11 90. NONE 0 99.OTHE-R (specify): <br />_ff -4. <br />- <br />464L <br />VR PRIMARY CONTAINMENT 1. STEEL FIBERGLA �S [3 10. RIGID - PLASTIC <br />0 90. NONE 0 99. OTHER (Specify): <br />464fl., <br />4648. <br />- ❑ 1. STEEL ®4. FIBERGLASS 10. RIGID PLASTIC D 90. NONE 0 99. OTHER (Specify): <br />` <br />464,81. <br />464h. <br />VENT PIPIAlG TRANSITION SUMP TYPE -` - --._.�0 <br />L 0 2. DOUBLE WALL D 90. NONE <br />4601. <br />4641. <br />RISER PRIMARY CONTAINMENT ❑ !. STEEL ®4: FIBERGLASS 0 10. RIGID PLASTIC ❑ 90. NONE 0 99. <br />y <br />464j.. <br />��'- --------- <br />RISER SECONDARY CONTAINMENT ❑ 1. STEEL ®4, FIBERGLASS 0 RIGID PLASTIC 90. NONE ❑0 99, OTHER (Specify <br />_4641. <br />46^j1Y- <br />464k, <br />FILL COMPONENTS INSTALLED ET PROTECTOR C451a <br />CONTAINMENT S`Ump <br />c. <br />VII. UNDER DISPENSER CONTAINMENT (UDC) <br />CONSTRUCTION TYPE SINGLE WALL El 2. DOUBLE WALL 0 1, NO D1§jPENSERS,_._. 0 90, NONE <br />CONSTRUCTION MATERIAL ❑ <br />_pLAsTIC�9_b <br />1. STEEL 4. FIB&_GjAj_S_6 to. jiIGID D 99. OTHER (Specify) <br />4469c. <br />VIII. CORR6SI0_NPROTECTION <br />'PROTECTION <br />STEEL COMPONENT El 2. SACRIFICIAL ANODE(S) 0 4. IMPRESSED CURRENT ❑ 6, ISOLATION <br />448. <br />IX- APPLICANT SIGNATURE <br />CERTIFICATION: I certify That this UST system is compatib-lewitit the hazardous substance stored and that the information provided herein is true, <br />accurate, and in full coal 1*14"ce with le al r!qq!wments._ <br />APPLICANT SIGNATURE qlzff7!� DATE 09/18/2008 <br />470. <br />APPLICANT NAME (priw) JEFF L'ARS-. 471 <br />EN <br />APPLICANTTITLE DIRECTOR OF HS&E <br />472. <br />UPCF UST -B Rev. (12/2007) - 1/2 www.uiiidm.org <br />