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IRNIFIED PROGRAM CONSOLIDATED FL . UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION.(One form per UST) [TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,II,III,IV,and IX below) 430 ❑ 1.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 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use On(y) BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Flying J Travel Plaza-#618 BUSINESS SITE ADDRESS 103 CITY l04 1501 N. Jack Tone Rd Ri on II.TANK DESCRIPTION. TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 A ®1.A STAND-ALONE TANK T-1 T' 1 CJ J �� + El2.ONE IN A COMPARTMENTED UNIT, Xerxes complete one page for each compartment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN TETE UNIT 437 12/94 2•kCIAN 20,000 I III.TANK USE AND.CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.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: ❑ l a.REGULAR UNLEADED ❑ I c.MIDGRADE UNLEADED ❑ ib.PREMIUM UNLEADED 440 ® 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL [19.OTHER PETROLEUM (Specify): 44oa NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL E] 11.OTHER NON-PETROLEUM(Specify): 44ob IV. TANK•CONSTR'UCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL El95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ L STEEL N 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ L STEEL ®3,FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 445a OVERFILL PREVENTION ® 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 ®2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 29 1.PRESSURE ❑ 2,GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(a)(3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGIDPLASTIC 461 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL L9 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ® I.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL W 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4644 46441 VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBBROLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 464f 464fl VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4648 464 1 VR SECONDARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS [110.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 4641. RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 4641 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464kl FILL COMPONENTS INSTALLED ® 1.SPILL BUCKET ® 3.STRIKER PLATE/BOTTOM PROTECTOR ® 4,CONTAINMENT SUMP 451 s-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 99.OTHER(Specify) 469b-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 compliance with legal requirements. azo. APPLI DATE LI ANT NAME(print) 471' APPLICANT TITLE 472. Joey Cupp Environment Management UPCF UST-B-2123 Rev.(12/2007)