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UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK • OPERATING PERMIT APPLICATION-TANK INFORMATION(ane form per US`I TYPE OF ACTION (Check one item only. For an UST permanent closure or removal,complete only this section and Sections 1,11,CII,IV,and IX below) 430 ❑ 1,NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE 0 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4304 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION I q q 6 1 1 FACILITY ID#(Agency Use Only) _ BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Flying J Travel Plaza-#617 BUSINESS SITE ADDRESS 103 CITY 194 15237 N.Thomton Rd Lodi U.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 437 TANK CONFIGURATION: THIS TANK 1S 434 1,A STAND-ALONE TANK 1-Regular �/ S ❑2.ONE IN A COMPARTMENTED UNIT. Complete one Past for each com artment 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 ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE On nudes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC§252&1,5(c)) ❑ 6,OTIIFR GENERATOR FUEL 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: 1 a.REG LF,ADED ❑ lc,MIDGRADE UNLEADED ❑ I b.PREMIUM UNLEADED 440 ❑ S.JET FUEL ❑ 6,AVIATION GAS ❑ 8,PETROLEUM BLEND IlLL Q9,071IER PETROLEUM (Specify): 440a NON-PETROLEUM:El7.USED OIL ❑ 10.ETHANOL ❑ 11,OTHER NON-PETROLEUM(S it ); 440b IV. TANK.CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL Q 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1,STEEL ® 3.FIBERGLASS ❑ 6,INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S xtif 444a • SECONDARY CONTAINMENT ❑ 1.STEEL 3.FIBERGLASS ❑ 6:EX ERIOR MEMBRANE LINER METED 445 ❑ 90,NONE ❑ 95.UNKNOWN ❑99,OTHER cif 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL,ALARMS ;2.BALL FLOAT 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 0 2,DOUBLE•WALLED ❑99.OTHER 460 SYSTLM TYPE ® 1.PRESSURE 2.GRAVITY 0 3.CONVENTIONAL SUCTION 0 4.SAFE SUCTION 123 CCR,jL63R%XI)l 459 PRIMARY CONTAINMENT 0 1.STEEL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHF,R(. i ): 4641 SECONDARY CONTAINMENT 0 1,STF,EI. Cl 4.FIBERGLASS ❑ 8,FLEXIBLE ❑ 10.RIGID PLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specie): 464c PIPINGMJRBINE CONTAINMENT SUMP TYPE 10 1.SINGLE WALL 2,DOUBLE WALL ❑ 90.NONE 4644 VI-VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT Ll I.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC a 90,NONE 0 ",OTHER(Specify) 4640 46401 VENT SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE E3 99,OTHER(Specify) 464( 464n VR PRIMARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC E3 90,NONE 99.On IER(Specify) 464 1t VR SECONDARY CONTAINMENT 1.STEEL 9 4,FIBERGLASS 0 to.RIGID PLASTIC 90.NONE C3 99.OTHER(Specify) 464h 464hl VENT PIPING TRANSITION SUMP TYPE 0 1.SINGLE WALL Q 2.DOUBLE WAIL 0 90.NONE 464'• RISER PRIMARY CONTAINMENT 29 1.STEEL LI 4.FIBERGLASS U 10,RIGID PLASTIC U 90,NONE U 99;OTI IER(Specify) 4641 4yj I RISER SECONDARY CONTAINMENT 1.STEEL 0 4.FIBERGLASS 13 10.RIGID PLASTIC E3 90,NONE 0 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET F1 3,STRIKER PLATEMOTTOM PROTECTOR 1@ 4.CONTAINMENT SUMP 451" VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 1,SINGLE WALL ❑ 2.DOUBLE.WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469* CONSTRUCTION MATERIAL ❑ 1.STEEL N 4.FIBERGLASS ❑ 10.RIGID PLASTtC 0 99,OTHER(Specify) 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODR(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, 40 In full compliance with legal requirements. DATE 470. Al Z"I T r��,� March 15 2012 1CANT NAME(print) 471' APPLICANT TITLE 472 Joey Cupp Environment Management UPCF UST-B-2/12 Rev.(12/2007)