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wl rr' Q UNIFIED PROGRAM CONSOLIDATED FORM 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 1,II,i1I,iV,and iX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ S.CHANGE OF INFORMATION 6.TEMPORARY UST CLOSURE 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430. 1 DATE EXISTING UST DISCOVERED: 430h I. FACILITY INFORMATION FACILITY ID S(Agency Use Only) 1 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 rlying J Travel Plaza-t#617 BUS iNESSSITE ADDRESS 103 CITY 1O9 15237 N.Thomton Rd Lodi II.TANK DESCRIPTION TANK 1D g (' 412 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK iS 434 �� 1 L ®1.A STAND-ALONE TANK ❑2.ONE IN A COMPARTMENTED UNIT. ]-Regular )(ERY V Complete ong ous for each mm artmeni in the unit DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 20000 1 M.TANK USE AND CONTENTS TANK USE 0 la.MOTOR VEHICLE FUEIJNG ❑ ib.MARINA FUELING ❑ 1c.AVIATION FUELING 479 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includa Und oil) ❑ 5.EMERGENCY GENLRATOR FUEL[HSC§25291.5(.)] ❑ 6.O'i'I[FR GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Spociry): 4390 CONTENTS PETROLEUM: N la.REGULAR UNLEADED ❑ ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 44n ❑ 3,DIESEL. ❑ 5.JET FUEL ❑ 6.AVIATION GAS (38.PETROLEUM BLEND FULL E] 9.OTHER PUMOI.F.UM S iT 4400 NON-PETROLEUM:❑ 7.USED OiL 0 10.ETHANOL ❑ 11.OTHER NON-PFTROLEUM(S if): 4406 IV. TANK CONSTAOCTION TYPE OF TANK 0 1.SINGLE WALL ® 2.DOUBLE WALL 95.UNKNOWN 443 PRIMARY CONTAiNWNI T ❑ 1,STEEL 3,FIBERGLASS ❑ 6.INTERNAL BLADDER A" ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S cif 444a SECONDARY CONTAINMENT 1.STEEL IB 3.FERGLASS ❑6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER cit 445" OVERFILL PRF.VF THON 0 I.AUDIBLE&VISUAL A3,ARMS 2.BALI,FLOAT 3.FILL TURF SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFI.I,PREVENTION EQUIPMENT V PROD'UtT/1VASTE PIPING CONSTRUCTION PiPING CONSTRUCTION 0 1.SINGLE-WALLED O 2.DOUBi.iL•WAL.LED Q 99.OTHER 460 SYSTEM TYPE ® 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION 23 CGA.§26D6 OM AS11 PRIMARY CONTAINMENT I.STEEL :4.FIBERGLASS &FLEXIBLE 10.RIGID PLASTIC, 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99,0THER( i ): 464a SECONDARY CONTAINMENT ❑ 1.STEEL. a®.i.FIBERGLASS 8.FLEXIBLE 10_RIGID PLASTIC 464b ❑ 90.NONE ❑ 95.UNKNOWN 99,OTHER(SpeeiryX. 464c PiPINGII URBiNE CONTAINMENT SUMP TYPE 1.SINGLE WALL 2.DOUBLE WALL 0 90.NONE 4644 VI.VENT,VAPOR RECOVERY(VR)AND RISER/KP1WPIPE PIPING_CONSTRUCTION VENT PRIMARY CONTAwmixr 1.STEEL 4.FIBERGLASS El 10.RIGID PLASTIC C1 90.NONE C3 99.011IER(Specify) 4640 1640 VENT SECONDARY CONTAINMENT ❑ I.STEEL R 4.FIBERGLASS 0 10,RIGiD PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10,RiGID PLASTIC 0 90,NONE 0 99.OTIIER(Specify) Oma 4(Aal VR SECONDAR Y CONTAINMENT 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464h 4601 VENT PIPING TRANSITION SUMP TYPE 0 L SINGLE WALT: 2.DOUBLE WALL 0 90.NONE 464L RISER PRIMARY CONTAINMENT 0, 1.STEEL 4.FIBERGLASS 0 10,RIGID PLASTIC U 90,NONE 99.011111R(Specify) 4641 464 1 RISER SECONDARY CONTAINMENT I.STEEL 0 4.FIBERGLASS C3 10,RIGiD PLASTIC 90.NONE C1 99,OTHER(Specify) 464E 464k1 FILL COMPONENTS INSTALLED I.SPiLL BUCKET M 3,STRIKER PLA rE1B01TOM PROTECTOR 19 4.CONTAINMENT SUMP 451aw Vfl VNDERUISPENSER CONTAINMENT(tJDC).; CONSTRUCTION TYPE 1.SINGLE WALL ❑ 2.DOUBLE WALL. ❑ 3.NO DISPENSERS ❑ 90.NONE CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC 0 99.0THER(5 city) 46M.t VIII, CORROSION PROTECTION STEEL,COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION °" " s 443- IX -APP%f1QGANT SIGNAT 7RE CERTiFiCATiON: i certify that this UST system is compatible with the hazardous substance stored and that the information provided herein Is trio;4urate, In full compliance with legal requirements. 47c. AP DATE March 15 2012 1CANT NAME(print) 411" APPLICANT TiTLE 'a'.." "" 47z Joey Cupp Environment Management awr.I UPCF UST-B-2/12 Rev,(12/2007)