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Ac • vi 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,Il,Ill,IV,and IX below) 430 ❑ 1,NEW PERMIT N 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE Ej 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4304 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 3 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) / 3 Flying J Travel Plaza-#617 BUSINESS SITE ADDRESS 103 CITY 104 15237 N,Thomton Rd Lodi 11.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 474 �,,, ®1.A STAND-ALONE TANK 2- Re lar t {� ❑2.ONE IN A COMPARTMENTED UNIT. 1 `�� Co fete one Page for each wm rtment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN TI IE UNIT 437 20000 1 III.TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING Cl Ic.AVIATION FUELING 439 ❑ 3,CI WMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used Oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281.5(c)) ❑ 6.OTHER GENE 5,UNKNOWN ❑ 99.OTHER (Specify): 4394 CONTENTS PETROLEUM, la.REGULAR UNLEADED j ❑ lc.MIDGRADE UNLEADED ❑ Ib PREMIUM UNLEADED 440 ❑ 5,JET FUEL ❑ 6_AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL 9.OTHER PETROLEUM S if ; 440a NON-PF,TROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 440b IV. TANK CONSTRUCTION' TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LIMNG ❑ 95.UNKNOWN ❑ 99,OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.S11',EL 111,FIBERGLASS 0 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 • 90.NONE ❑ 95.UNKNOWN ❑99.OTHERS i 4454 OVERFILL.PREVENTION I,AUDIBLE&VISUAL ALARMS El 2.BALI.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 ®2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 1.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION 4.SAFE SUCTION 123 CCR§2636(.X3)) 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4,FiBEROLASS 8,FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95,UNKNOWN ❑ 99.OTHFil Y): 464a SECONDARY CONTAINMENT ❑ 1.STFFL ® 4.FIBERGLASS ❑ 8.FLEXIBLE ❑ 10.RIGID PLASTIC 460 ❑ 90,NONE ❑ 95.UNKNOWN ❑ 99.OTHER(S i : 464e PIPING/TURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 46444 VI.VENT,VAPOR RECOVERY(VR)AND'RISER 7 FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT 0 1.STEEL ® 4.FIBERGLASS 0 10,RIGID PLASTIC El90 NONE. ❑ 99,OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT 1,STEEL 0 4.FIBERGLASS 0 10,RIGID PLASTIC fj90.NONE 99.OTHER(Specify) 464r 464n VR PRIMARY CONTAINMENT E3 i.STEEL t9 4,FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 0 99.OTHER(Spccily) 4648 464 i VR SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 90.NONE E3 99,OTHER(Specify) 46411 464h1 VENT PIPING TRANSITION SUMP TYPE 1,SINGLE WALL 2,DOUBLE WALL. IM 90.NONE 4641. RISER PRIMARY CONTAINMENT IN 1,STEEL U C FIBERGLASS U 10.RIGID PLASTIC U 90;NONE U 99,OTHER(Specify) 464J RISER SECONDARY CONTAINMENT 0 1.STEEL 0 4.FIBERGLASS 10,RIGID PLASTIC 90.NONE 0 99.OTHER(Specify) 4648 4601 FILL COMPONENTS INSTALLED 0 1.SPILL BUCKET 0 3.STRIKER PLATEIB07TOM PROTECTOR 0 4.CONTAINMENT SUMP 451a-e V11.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 46% CONSTRUCTION MATERIAL Ej 1.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC 0 99,0TF1ER(S ci ) 46Wc VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 448. DL 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, -pod in full compliance with lepi requirements. APPLIC N DATE 070 • A71 March 15 2012 472' AP (CANT E(print) APPLICANT TITLE Joey Cupp Environment Management UPCF UST-B-1/12 Rev.(12/2007)