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u_E. i2 UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK �,t OPERATING PERMIT APPLICATION-TANK INFORMATION(One form per tJST') • TYPE(7F ACI-ION (Check one item only. Foran UST permanent closure or removal,complete only this section and Sections 1,Ii,III,IV,and TX below) 436 J ❑ L NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE El 8.USTREMOVAL DATE UST PERMANENTLY CLOSED; Q. 1 DATE EXISTING UST DISCOVERED: 4306 L FACILITY INFORMATION 1 FACILITY 1D#(Agency Use Only) TF1. BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) 3 Flying J Travel Plaza-#617 BUSINESS SITE ADDRESS 103 1 CiTY 104 15237 N.Thornton Rd Lodi H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 \i ®1,A STAND-ALONE TANK 5-Premium U J`��1+ J ❑2.ONE IN A COMPARTMENTED ONIT. Complete one pose far each com erlmont in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS u6 NUMBER OF COMPARTMENTS IN THE UNIT 837 12000 I III.TANK USE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ ib.MARINA FUELING ❑ lc,AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE. ❑ 4.HAZARDOUS WASTE(includes Used oil) ❑ 5,EMERGENCY GENERATOR FUEL[HSC§25281 5(c)) ❑ 6,OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 439' CONTENTS PETROLEUM; ❑ la.REGULAR UNLEADED ❑ 1 c.MIDGRADE UNLEADED ® 1 b,PREMIUM UNLEADED 440 O 3.DIESEL ❑ S.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4408 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUMS cif r 4401, IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL ® 3.FiBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL.t.INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTlIHR (5 if 444a SECONDARY CONTAINMENT ❑ 1.STF.'EL 3.FIBFR(U ASS 6.EXTERIOR MEMBRANE LINER 7,J I ETED 445 • ❑ 90.NONE ❑ 95,UNKNOWN ❑99"OTHER( if 445a OVERFILL.PREVENTION 1.AUDIBLE&VISUAL ALARMS ;2,BALI.FLOAT 3.FiLL TU13E SHUT-OFF VALVE 452 ❑ 4.TANK MEETS RL'QUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PiPING CONSTRUCTION ❑1.SiNGLE-WALLED 0 2.DOUBLE-WALLED ❑99,077TER 460 SYSTEM TYPE ® I.PRESSURE ❑ 2.GRAVITY3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 2.1 CCR§2rtWs)(3)) 459 PRIMARY CONTAiNMENT ❑ 1.STEEL 4.FIBF,RGLASS 8,FLEXIBLE ❑ 10.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99,OfHERIN if): 464a SECONDARY CONTAINMENT ❑ I.STEEL, 4,FIBERGLASS 8,FLEXIBLE ❑ 10.RIGiD PLASTIC 4646 ❑ 90.NONE Q 95.UNKNOWN ❑ 99.OTHER Si : 464c PIPING/TURBINE CONTAINMENT SUMP TYPE ISI 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 464d VL VENT,VAPOR RECOVERY(VR)AND RISER/FILLPIPE PIPING:CONSTRUCTION VENT PRIMARY CONTAINMENT 1.STEEL 9 4,FIBERGLASS Ej 10.RiGID PLASTIC 0 90,NONE ❑ 99,OTHER(Specify) 464e 464c1 VENT SECONDARY CONTAINMENT El 1.STEEL 0 4,FIBERGLASS i0.RIGID PLASTIC 90.NONE 99.OTHER(Specify) 464f 464n VR PRIMARY CONTAINMENT El 1.STEEL 9 4.FiBERGLASS 0 10.RIGID PLASTIC 90.NONE 99,OTHER(Specify) x648 464g) VR SECONDARY CONTAINMENT 1.STEEL, 3 4,FIBERGLASS 10,RIGID PLASTIC 13 90.NONE 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMPTYPF i..SiNGI.E WALL 2.DOUBLE WALL M %NONE 464, RISER PRIMARY CONTAINMENT 99 I.STEEL 0 4,FIBERGLASS U 10.RIGID PLASTIC U 90,NONE U 99,OTHER(Specify) 4" 46411 RiSER SECONDARY CONTAINMENT 0 I.STEEL 0 4.FIBERGLASS 0 10.RIGID PLASTIC El 90,NONE 0 99.OTHER(Specify) 460 46441 FILL COMPONENTS INSTALLED 0 1.SPiLL BUCKET 0 3,STRIKER PLATcA30TTOM PROTECTOR 0 4.CONTAINMENT SUMP 45la-c VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1,SiNGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS (] 90.NONE 469a CONSTRUCTION MATERIAL ❑ 1.STEEL 0 4,FIBERGLASS 0 IO.RIGID PLASTIC 0 99.OTHER(Specify) 469b-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT R 6.ISOLATION 443' 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, and in full co lance with legal re uirements. APP E DATE 470 March 15 2012 AP T N E(p mt) 471, APPLICANT TITLE 472' bey Cupp Environment Management UPCF UST-B-1/12 Rev,(12/2007)