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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 I,Il,Ill.IV,and IX below) 430 ❑ L NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE El 7.UST PERMANENT CLOSURE ON SITE Q 8.UST REMOVAL DATE.UST PERMANENTLY CLOSED: 430s 1 DATE EXISTING UST DISCOVERED: 430b I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) 1 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.Thornton Rd Lodi II:TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 474 �1.ASTAND-ALONE TAN K 4-Regular 2.ONE M A COMPARTMENTED UNIT. C We ax Page ax wh owswinm i.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 ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(includes Used oil) ❑ 5.EMERGENCY GENERATOR FUEL[HSC§25281 5(yl ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439a CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNr.EADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6,AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9,OTHER PETROLEUM S iry): 440a NON-PETROLEUM:❑ 7.USED 011. ❑ 10.ETHANOL ❑ 11,OTHER NON-PETROLEUM(S cif): 4406 IV. TANK CONSTRUCTION TYPE OF TANK Cl 1.SINGLE WALL ® 2.DOUBLE WAIL ❑ 95.UNKNOWN 4443 PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 El 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S scoif): 444' SECONDARY CONTAINMENT Ej 1.STEEL 6 3.FIBERGLASS 6,EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 • ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specif}: 445a OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALLMOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUfRETAhNTS FOR EXEMPTION FROM OVERFILL PREVFN71ON EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION_ PIPING CONSTRUCTION ❑1.SINGLE-WALLED 0 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 0 1.PRESSURE, ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 21 CCR 2636(s)(3 459 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS 0 $.FLFXIBLE ❑ 10.RIGIDPLASTIC 464 90.NONE ❑ 95.UNKNOWN ❑ 99.01FIER( if): 464s SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 8.FT.FXIBI,E 0 10.RIGID PLASTIC 464h ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99,OTHER(Specify): 464c PIPINGrIURBINE CONTAINMENT SUMP TYPE 0 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VL VENT,VAPOR RECOVERY(VR)AND RISER/'FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL 0 4,FIBERGLASS 0 10.RIGID PLASTIC ❑ 90.NONE 0 99.OTHER(Specify) 464c 4640 VENT SECONDARY CONTATNMI NT" 0 L STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC El 90,NONE El 99.OTHER(Specify) 464r 464n VR PRIMARY CONTAINMENT 1.STEEL X 4,FIBERGLASS 0 10.RIGID PLASTIC o 90,NONE 99.OTIin(Specify) 4649 6 VR SECONDARY CONTAINMENT I.STEIiL 10 4,FIBERGLASS Cl 10.RIGID PLASTIC 0 90,NONE 13 99.OTHER(Specify) 464h 4601 VENT PIPING TRANSITION SUMP TYPE 1.SINGLE WALL 2,DOUBLE VJA.LL 90.NONE 4641, RISER PRIMARY CONTAINMENT Q9 1.STEEL. E3 4.FIBERGLASS [0.RIGID PLASTIC U 90.NONE 99.OTHER(Specify) 4641 464i) RISER SECONDARY CONTAINMENT 0 1.STEEL, C9 4.FTBERGLASS 0 10.RIGID PLASTIC 0 90,NONE t3 99.OTHER(Specify) 464k 4601 FILL COMPONENTS INSTALLED 0 1.SPILL.BUCKET 3,STRIKER PI.ATE/BOTTOM PROTECTOR 0 4,CONTAINMENT SUMP 451a- VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 469A CONSTRUCTION MATERIAL ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 99.OTFIER(S ci 469L-o VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODF.(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 449 1(X. 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, and In full com liance with legal re uircments. APPLIC DATE 470. • PLI AM (print) a71. APPLICANT TITLE 472 !JO Cupp Environment Management UPCF UST-B-1/12 Rev.(12/2007)