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UINEVIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION- TANK INFORMATION (Onl:f-nnper UST) T7====== TYPE OFACTION (Check one item only. For a UST closure orremoval. con?P717only toes section and Sections 1, 11, 111, IV and T.r_b,7,-,) 1. NEW PERMIT 4307❑ 1 [9 3. RENEWAL PERMIT' 0 5. CHANGE OF INFORMATION ❑ UST CLOSURE 6. TEMPORARY Ej 7. UST PERMANENT CLOSURE ON SITE 0 8. UST REMOVAL DATE UST PERMANENTLY CLOSED: 430a- DATE EXISTING UST DISCOVERED: 430b. L FACILITY INFORMATION FACILITY ID # (Agency Use Only) BUSINESS NAME (Same as Facility Name or DBA - Doing Business As) FLYING J TRAVEL PLAZA 3. Eiu_-smss SITE ADDRESS 103. CITY 1501 NORTH JACK TONE ROAD ---------------------------------- RIPON 104, 111. TANIK DESCRIPTION TANK ID # 432- TANK MANUFACTURER 433. TANK CONFIGURATION: THIS TANK IS 434. 3 OWENS CORNING N L A STAND-ALONETANK Complete one page rar rach 0 2. ONE IN A COMPARTMENTED ❑CAPACITY DATE LIST SYSTEM INSTALLED 43s- TANK IN GAL 43-6. GALLONS UNIT compartment in the mfit. NUMBER OF COMPARTMENTS IN THE UNIT 437� 12/1994 20,000 III. TANK USE AND CONTENTS TANK USE 0 Ia. MOTOR VEHICLE FUELINGtb. MARINA HAZARDOUS LING 0 Ic. AVIATION FUELING 4397 0 3. CHEMICAL PRODUCT STORAGE [:1 ❑4. WASTE (Ittell.d. Wed Oil) 11 S. EMERGENCY GENERATOR FUEL[HSC §25281.5(c)] 0 6. OTHER GENERATOR FUEL 0 95. UNKNOWN 0 99. OTHER (Specify): 439a. CONTENTS PETROLEUM: _ El I.. REGULAR UNLj��D_EjjE]1_c, MIDGRADE UNLEADED _0 Tb. _PREMIUM UNLEADED ED 3. DIESEL 446 0 5. JET FUEL El 6. AVIATION GAS El 8. PETROLEUM BLEND FUEL 0 9. OTHER PETROLEUM (Specify): -7,---'-------' - 440a. N&NP-EfFO-LEUI-vi..[jUSED OIL 0_10i._ETHANOL ❑ 1. OTHER NON -PETROLEUM (5 eciry): 440b. IV. TANK CONSTRUCTION TYPE OF TANK El I. SINGLE WALL ED 2. DOUBLE WALL [71 95. UNKNOWN ' PRIMARY CONTAINMENT 0 I. STEEL FIBERGLASS' El 6. INTERNAL BLADDER 4437 [1 7. STEEL + INTERNAL LINING ❑ 95. UNKNOWN 11 99. OTHER (Specify): 444a - -'SECONDARY _C014fAINMENT [j I. STEEL ®3. FIBERGLASS❑ 6. EXTERIOR MEMBRANE 444. LINER 0 7, JACKETED El 90. NONE 13 95. UNKNOWN 0 99. OTHER (Specify)- 445a. OVERFILL PREVENTION ____0 2. BALL FLOAT 9 1. AUDIBLE & VISUAL ALARMS 4 3. FILL TUBE SHUT-OFF VALVE 0 4. TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL 452. PREVENTION _E2UIPMENT V. PRODUCT I WASTE PIPING CONSTRUCTION PIPING PIPING CONSTR C 1. SINGLE WALL 02. T'ON '3 - 11 - DOUBLE WALL rl 99 OT ER T TYPE Ig SYSTEM ITYYPE 1. PRESSURE U 2. GRAVITY 0 3. CONVENTIONAL SUCTION 0 4. SAFE SUCTION r23 CCR §,636(a 3)] PRIMARY0 _ C CONTAINMENT CONTAINMENT I. STEEL 4i1_8ERdL_Ass -0 460. 458, 8 . FLEXIBLE ❑ 10. RIGID FLASTI� El _ 90, NONE D 95. UNKNOWN Ej 99. OT14ER (Specify): 4-64. E LR E 464a. Co YCO T M CONTAINMENT [3 1. STEEL 9 4. FIBERGLASS 0 8. FLEXIBLE 0 10. RIGID PLASTIC 464b. 0 90. NONE 0 95, UNKNOWN 11 99. OTHER (SpeSLfy): 464c. PIPING/TURBINECONTAINMENT SUMP,TYPE 0 ).SINGLE WALL U 2. DOUBLE WALL0 90. NONE 4644. VI. VENT, VAPOR RECOVERY AND RISER / FILL PIPE . PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 I. STEEL - 4. FIBERGLASS 0 10. RIGID PLASTIC [I90. NONE [] 99. OTHER (Specify): 46-4iT.- VENT SECONDARY CONTAINMENT El LSTEEL FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE El 99. OT14ER 464e1__ 464f S (pecify): VR PRIMARY CONTAINMENT-` 0 STEEL 4. FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE ❑ 99. 464n; 4649. OTHER (Specify): VR SECONDARY 464al. CONTAINMENT 1. STEEL Cj 4, FIBEkGLASS 0 10. RIGID PLASTIC El 90. NONE [3 99. OTHER (Specify): _7VENT 464h. PIPING TRANSITION SUMP TYPE LSINGL.WALL [3 2. DOUBLE WALL D 90. NONE _iISEF�PRIMARY 464hL 464i, CONTAINMENT [I LSTECL 4.FfBERGLASS 0 JO.RIGID PLASTIC 0 90, NONE 0 99. OTHER (Specify): 1 RISER SECONDARY CONTAINMENT 0 I. STEEL 4. FIBERGLASS 0 10. RIGID PLASTIC ❑ 90. NONE E j 464t 1. 464k 99. OTHER (Specify): FILL COMPONENTS INSTALLED 464kl. 9 1. SPILL BUCKET Sr 3. STRIKER PLATEIBOTTOM PROTECTOR 4. CONTAfNMLNT SUMP 451ac. VII. UNDER DISPENSER CONTAINMENT (UDC) CONSTRUCTION TYPE I . SINGLE WALL 2. DOUBLE WALL 0 3. NO DISPENSERS 0 90 NONE_____ CONSTRUCTION MA MATERIAL 469a, LSTEEL 1@ 4. FIBERGLASS El 10. RIGID PLASTIC n 99. 0 46W - VIII. CORROSION PROTECTION 469e. STEEL COMPONENT PROTECTION ❑ 2 SACRIFICIAL AND )E(S) El 4. IMPRESSED CURRENT [1 6. ISOLATION 448. IX. APPLICANT SIGNATUREN1 System is CERTIFICATION. I certify that this U compatible with the hazardous substance stored and that the information provided herein is true, accurate, and in full compliance with fegal requirements. APPLICANT SIGNATURE�� DATE 09/18/2008 470. APPL)CANTNAME (prino JEFF LARSEN 471. APPLICANTTITLE DIRECTOR OF HS&E 472. UPCF UST -B Rev. (12/2007) - 112 www.unidocs.org