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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION - TANK INFORMATION (One form per UST) TYPE OF ACTION (Check one item only. Fora UST closure or remora!, COMPIele only this section and 'Sections '4'7,711, X and 430 El 1. NEW PERMIT X 3. RENEWAL PERMIT 0 5. CHANGE OF INFORMATION 0 6. TEMPORARY UST CLOSURE.. [__1 7. LIST PERMANENT CLOSURE ON SITE DATE UST PERMANENTLY CLOSED: 7__ __- El . ,-. - 8. UST. REMOVAL I. FACILITY INFORMATION FACILITY ID # (Agency Use Only) I I I I-3---i---i-7--e- BUSINESS --- r_-T--T---1-r- UPCF UST -B Rev. (12/2007) -1/2 www.unidoes.org BUSINESS NAME (Same as FocffiV Name or DBA - 5angBmine�s.,As) L I I I FLYING J TRAVEL PLAZA 3. BUSINESS SITE ADDRESS 103, CITY 1501 NORTH JACK TONE ROAD RIPON 104. H. TANK DESCRIPTION TANK ID# 432. TANK MANUFACTURER 433- TANK CONFIGURATION: THIS TANK IS 434, 4 OWENS CORNING 0 1. A STAND-ALONE TANK Complete one page for each DATE LIST SYSTEM INSTALLED 435. - TANK IN GALLONS 436. 0 2. ONE IN A COMPARTMENTED UNIT comp4riment in the ❑CAPACITY NUMBER OF COMPARTMENTS IN THE -UNIT unit. 437. 12/1994 . ...... 1 12,000 1 IR. TANK USE AND CONTENTS TANK USE CK In. MOTOR VEHICLE FUELING [3 lb. M lRINA FUELING 0 Ic. AVIATION FUELING 439. 0 3.CIIEMICAL PRODUCT STORAGE D 4. HAZARDOUS WASTE (Includes Used Oil) 11 5. EMERGENCY GENERATOR FUEL[HSC §25281-5(c)] 0 6. 0111ER GENERATOR FUEL El 95. UNKNOWN 0 99. OTHER (Specify): 4390. CONTENTS PETROLEUM: ®la. REGULAR UNLEADED E3 1c. MIDGRADE UNLEADED 0 lb. PREMIUM UNLEADED 4407 El 3. DIESEL [:3 5. JET FUEL ❑ 6. AVIATION GAS 1:1 8. PETROLEUM BLEND FUEL 1--] 9. OTHER PETROLEUM (Specify): 4400. NON-PETROLEUM:NON-PETROLE. 0 7. USED OIL _ U 10. ETHANOL 0 1(. OTHER NON -PETROLEUM (S cc �l ); 440b. IV. TANK CONSTRUCTION TYPE OF TANK C1 1. SINGLE WALL 19 2. DOUBLE -WALL ff _95UNKNOWN 443. ,_ PRIMARY CONTAINMENT 0 1. STEEL C9 3. FIBERGLASS -_E1 6. INTERNAL BLADDER 444. _ 7. STEEL '- INTERNAL LINING 1395. UNKNOWN [1 99. OTHER( �p ecify): 444a. _❑ f _.- SECONDARY CONTAINMENT 13_TSTEECff3. FIBERGLASS - - -MEMBRANE 0 6. EXTERFOR LINER ff 7. JACKETED _!O. NONE 0 95, UNKNOWN 0 99. OTHER (Specify): 443. _ 445a. OVERFILL PREVENTION I. AUDIBLE& VISUAL ALARMS 0 2. BALL FL -OAT--' D9 3. FILL TUBE SHUT-OFF VALVE ❑ 4. TANK MEETS REgUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT / WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑ I. SINGLE WALL 0 1 DOUBLE WALL 0 99. OTHER SYSTEM TYPE 1. PRESSURE [1 2. GRAVITY _ff 3. CONVENTIONAL SUCTION Q 4. SAFE SUCTION 123 SCR §2636(4) 3)1 -PRIMARY CONTAINMENT 0 1. STEEL 0 4. FIBERGLASS 460. _43K 0 8. FLEXIBLE 11 10. RIGID PLASTIC ❑ 90. NONE 0 95..UNKNOWN 0 99. OTHER (Specify): 464. 464a. S9C0N_D;ikf CONTAINMENT 13 I-STEC- D-9 4. FIBERGLASS 13 B. FLEXIBLE 0 10. RIGID PLASTIC 4646, E] 90. NONE ❑ 95. UNKNOWN 0 99. OTHER (Specify): 464c. PIPING/TURBINE CONTAINMENT SUMP TYPE I. -siNr.LE NALL El 2. DOUBLE WALL1] 90, NONE 464d. -_V1. VENT, VAPOR RECOVERY (VR) AND RISER / FILL PIPE PIPING CONSTRUCTION VERT PRIMARY CONTAINMENT 0 LSTEEL 19 4. FIBERGLASS[__1 10. RIGID PLASTIC 0 90. NONE 13 99. OTHER (Specify)., 464e. VENT SECONDARY CONTAINMENT 0 1. STEEL 0 4. FIBERGLASS ❑13 10, RIGID PLASTIC ❑[1 90. NONE El 99. OTHER 4640. 464E (Specify): VR PRIMARY CONTAINMENT - 0 1. STEEL 19 4. FIBERGLASS 0 10. RIGID PLASTIC D 90. NONE Q 99. OTHER (Specify): 464n. 464g. CONTAINMENT' - VR SECONDARY CO 1. STEEL B'TFIBERGLZS 0 10. RIGID PLASTIC ❑D 90. NONE 0 99. OT14ER (Specify): 464gl. 464h. --VENT PIPING TRANSITION SUMP TYPE 19 1 -SINGLE WALL 0 2. DOUBLE WALL 0 90. NONE 464hL _4641. RISER PRIMARY CONTAINMENT ❑ 1. STEEL 19 4, FIBERGLASS 0 10. RIGID PLASTIC 0 90. NONE 0 99, OTHER (Specify): -464):- RISER SECONDARY CONTAINMENT ❑ I. STEEL _A_�j_t. 4.FIBERGLAss [I 10.RIGIDPLASTIC El 90. NONE ❑ 99.OTHFR(specif�): . 464k. FILL COMPONENTS INSTALLEDSPILL BUCKET 3. STRI PLATE/BOTTOM PROTECTOR 4, CONTAINMENT SUMP VU. UNDER DISPENSER CONTAINMENT "C) CONSTRUCTION TYPE ®1. SINGLE WALL0 2 . DOUBLE WALL [1 3. NO DISPENSERS 0 90. NONE - CONSTRUCTION MATERIAL 469a, D 1, STEEL 19 4, FIBERGLASS 0 10� RIGID PLASTIC 0 99. OTHER (Specify) - 469b VM. CORROSION PROTECTION 469e. STEEL COMPONENT PROTECTION ❑ 2. SACRIFICIAL ANODE(S), 0 4. IMPRESSED CURRENT 0 & ISOLATION 448. JX. APPIJCANT SIGNATURE CERTIFICATION: I certify that this UST sys(emis �compnfible with the hazardous substance stored and that the information provided herein is true, - accurate and In full complion e with Iegpd reg Irements. APPLICANT SIGNATURE DATE 09/18/2008 470. [APPLICANTNAME(print) JEFF LARSEN 471• APPLICANTTITLE DIRECTOR OF HS&E 471 UPCF UST -B Rev. (12/2007) -1/2 www.unidoes.org