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of <br /> • Ac, <br /> tsb c'i-j <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per US'I) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,Il,111,IV,and D(below) 430 <br /> ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE El 7.UST PERMANENT CLOSURE ON SITE ❑ 8,UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 4309 DATE EXISTING UST DISCOVERED: 430b <br /> I. FACILITY,INFORMATION <br /> FACILITY ID#(Agency Use Only) <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 <br /> FI ing J Travel Plaza-#617 <br /> BUSINESS SITE ADDRESS 103 CITY 104 <br /> 15237 N.Thornton Rd Lodi <br /> It.TANK DESCRIPTION <br /> TANK ID# 4l1 TANK MANUFACTURER 433 TANK CONT IGURATION:THT$'fANK is 434 <br /> 1 q OS / ®I.A STAND-ALONE TA?IK <br /> 2-Re ] r VV (X` IS[\'Yy 11�tJ ❑2.ONE IN A COMPARTMENTED UNIT. <br /> Complete one Pago for each corn rtmem in the unit. <br /> DATE.UST SYSTEM INSTALLED 433 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS M TIM UNIT 4)7 <br /> 20000 <br /> III.TANK USE AND CONTENTS <br /> TANK USE 0 to.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING <br /> 439 <br /> ❑ 3.CIILMCAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Used 010 ❑ 5.EMERGENCY GENERATOR FUEL[HSC;25281.s(c)] <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (S eri ): 4398 <br /> CONTENTS PETROLEUM: M la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 <br /> ❑ 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL Q 9.OTHER PETROLEUM S if ' 4401 <br /> NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11,OTHER NON-PETROLEUM(S4): 440b <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ L SINGLE WALL 8 2.DOUBLE WALL93.UNKNOWN 443 <br /> IM <br /> PRARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99,OTHER S cci ): 4448 <br /> SECONDARY CONTAINMENT ❑ 1.STT.m. M 3.FIBERGLASS Ej 6.EXTERIOR MEMBRANE LINTER ❑ 7.JACKETED 445 <br /> ❑ 0.NONE 95.UNKNOWN ❑99,OTHER i : 445a <br /> OVERFII.L PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALI,FLOAT 3.FILL TUBE SHUT-OFF VALVE 4$2. <br /> ❑ 4.TANK MEETS REQUIREMFNTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT I WASTE PIPING,CONSTRUCTION <br /> PIPING CONSTRUCTION ❑1,SINGLE-WALLED ®2.DOUBLE-WALLED [3 99.OTHER 460 <br /> SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION Lj 4.SAFE SUCTION 127 CCR¢2616(8 3) 438 <br /> PRIMARY CONTAINMENT ❑ 1.STEEL 4,FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC VA <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHFR(S if),. 4648 <br /> SECONDARY CONTAINMENT ❑ 1.STFF.L 4.FIBERGLASS 8.FLEXIBLE ❑ 10.RIGID PLASTIC QAb <br /> ❑ 90.NONE ❑ 95.UNKNOWN 99.OnIER i : 464c <br /> PiPINGn'URBTNF.CONTAINMENT SUMP TYPE ® 1.SINGLE WALL 2,DOUBLE WALL ❑ 90.NONE 464d <br /> VLVENT,VAPOR RECUVERY" AND-RISER%MII PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT U 1.STEEL 0 4.FIBHRGLASS 0 10.RIGID PLASTIC 90;NONE 0 99,OTHER(Specify) 464c <br /> 464e <br /> VENT SECONDARY CONTAINMENT 1.STEEL 0 4,FIBERGLASS 0 10,RIGID PI,ASTIC 0 90.NONE 99.OTHER(Specify) 464r <br /> 464(1 <br /> VR PRIMARY CONTAINMENT 1.ST CEL 0 4,FIBERGLASS 10.RIGIDPLASTIC 90.NONE 99.OTHER(Speciry) 444464g <br /> VR SECONDARY CONTAINMENT 1.STEEL CD 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 99,OTHER(Specify)' 464h <br /> 464h1 <br /> VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL 0 2.DOUBLE WALL 0 90.NONE 4641, <br /> RISER PRIMARY CONTAINMENP 0 I.STEEL 0 4.FIBERGLASS U 10.RIGID PLASTIC U 90.NONE 99:OTHER(Specify) 464) <br /> 4"T <br /> RISER SECONDARY CONTAINMENT 0 L STEF.I. 0 4.FIBERGLASS 0 10,RtGtUPLASTIC 90,NONE 13 99.OTHER(Specify) 464E <br /> 464k1 <br /> FILL COMPONENTS INSTALLED R I.SPILL BUCKBT' 3.STRIKER PL.ATEIBOTTOM PROTECTOR 94.CONTAINMENTSUMp 4Sma c <br /> 't'TI'UNl`IER`TJISp�1�5ETtGOI�'i1�ill�lVIEN{I:,(UD• � . <br /> CONSTRUCTION TYPF ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4691 <br /> CONSTRUCTION MATERIAL I.STEEL 0 4.FIBERGLASS 10,RIGID PLASTIC 99.OTIIER(S ir) 46Wc <br /> VIII. CORROSION`PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2,SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT N 6,ISOLATION <br /> IX. APPLICANT.SIGNATURE <br /> CERTIFICATION:I certify that this UST system is compatible with the hazardous substance stored and that the Information provided herein is trdoccitt`)Ite, <br /> nd in full compliance with legal requirements. <br /> APPLIC DATE <br /> March 15 2012 ' <br /> AP (CANT N04AE(print) 471` APPLICANT TITLE ala. <br /> Joey Cupp Environment Management , <br /> UPCF UST-B•1/12 Rev.(12/294)-j <br />