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Oi 5 3�� UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per us'r) TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections I,11,111,TV,and IX below) 430 [' 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ S.CHANGE OF TNFORMATION ❑ 6,TEMPORARY UST CLOSURE Ej 7.UST PERMANENT CLOSURE ON SITE- 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 430■ DATE EXISTING UST DISCOVERED: 430b I. FACIIITY INFORMATION FACILITY IDN(Agency Use Onfy) BUSINESS NAME(Same as FACILITY NAME or DHA-Doing Business As) 3 Flying J Travel Plaza-#617 BUSINESS SITE.ADDRESS 103 CITY 104 15237 N.Thornton Rd Lodi ILTANK DESCRIPTION TANK IDN 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 ®1.A STAND-ALONE TANK 3-Regular _7 V X F IZ)( S [12.ONE M A COMPARTMENTED UNIT, Co let.r for each cernpartment,n the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 20000 1 III.TANK USE`AND CONTENTS TANK USE ® 1a.MOTOR VFL{ICLE FUELING ❑ lb.MARINA FM...TNG ❑ I0.AVIATION FUELING 430 ❑ 3,CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ 5.EMERGENCY GENERATOR FIJEL(14SC V5281 Sic)) ❑ 6.OTHER GENERATOR FUEL ❑ W.UNKNOWN ❑ 99,OTHER (Specify): 439■ CONTENTS PETROLEUM: R 1a.REGULAR UNLEADED ❑ Ic.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3,DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ S.PETROLEUM BLEND FUSL ❑ 9.OTHER PETROLEUM Spacifv; 440■ NON-PETROLEUM:❑ 7.USED 011. ❑ 10.ETHANOL Q 11.OTHER NON-PETROLEUM(SpecifyY 440b IV. TANK CONSTRUCTION TYPE OI'TANK ❑ 1,SINGLE WALL 2.DOUBLE WALL 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS 6.INTERNALHLADDER 444 Q 7.STEEL+INTERNAL LINING ❑ 95.I�NKNOWN ❑ 99.OTHER f 444a SECONDARY CONTAINMENT I.STFF.L 3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER 7.JACKETED 445 90,NONE 95.UNKNOWN ❑99.OTHER S 1 445a OVERFILL PREVENTION I.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS RE UIRF.MENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUiPMLNT V. PRODUCT/WASTE:PIPING CONSTRUCTION PIPING CONSTRUCTION ❑1.SINGLE-WALLED .2.DOUBLE-WALLED [3'99.011-11M 40 SYSTEM TYPE ® I.PRESSURE ❑ .GRAVITY 3.CONVENTIONAL SUCTION 4.SAFE SUCTION 23 CCR¢2636(4 3 458 PRIMARY CONTAINMENT ❑ I.STEEL. 4.FIBERGI AS5 tt,FLEXIT3LE 10.R10TD PLASTIC 464 ❑ 90.NONE ❑ 5.UNKNOWN 99.OTHER(Specif : 4644 SECONDARY CONTAINMENT Q I.STEEL 4.FIBERGLASS s.FLEXIBLE 0 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN Q 99.071 TER(Specify): 4644 PIPINGITURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE. 4t✓d VI.VENT,VAPOR RECOVERY(VR).AND RISER/FILL PIPE PIPING CONSTRUCTION. VENT PRIMARY CONTAINMENT I.STEEL 0 4,FIBERGLASS 0 10,RIGID PLASTIC ❑ 90.NONE 99.0111FR(Specify) 4644 46441 VENT SECONDARY CONTAINMENT I.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE El 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT 1.SIT-11. 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE 0 99:OTHER(Specify) 44641; 46 8 YR SECONDARY CONTAINMENT 1.STEEL 0 4.FTBERGLASS 10,RIGID PLASTIC 90,NONE 0 99.OTHER(Specify) 464h 4641 VENT PIPING TRANSITION SUMP TYPE T.SINGLE WAIL. 0 2.DOUBLE WALL 90.NONE 4", RISER PRIMARY CONTAINMENT I.STEEL. 0 4.FITIERGLAS5 0 10.RIGID PLASTIC 90.NONE El 99,On (Specify) Wi 4"j1 RUST'R SECONDARY CONTAINMINT ❑ 1.STEIN, 0 4.FIBERGLASS E3 10,RIGID PLASTIC ❑ 90,NONE 0 99.OTHER(Spocify) 4641, 4641,1 ~FILL COMPONENTS INSTALLED 1.SPILL BUCKET 0 3.STRIKER PLATEIBOTTOM PROTECTOR 0 C CONTAINMENT SUMP 45Ie-c VII.UNDE"ISPENSEtCO'NT INMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3:NO DISPENSERS ❑ 90.NONE. 4698 CONSTRUCTION MATERIAL ❑ 1.STEEL IN 4.FIBERGLASS 0 10.RIGID PLASTIC 99.OTHER S ), tb9bw Vt7I, `CORROSION PROTECTION �' STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4,IWRESSED CURRENT ® 6.ISOLATION 448, IX. APPLICANTISIONAT,,URE'. CFXIVICAT1ONs t certify that this UST system Is compatible with the hazardous substance stored and that the Information provided herein is 04►e ccurste, and in fullpamplialace with lepl rc uirements APP A DATE 470, March 15 2012 AP ]CAk NAME(print 471 APPLICANT TITLE 474' Joey Cupp Environment Managements UPCF UST-B-1/12 14y.(12/2007)