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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 permanert closure Or removal,completeonly this section and Sections I,II,III,IV,and IX below) 470 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ 8.UST REMOVAL DATE UST PERMANENTLY CLOSED: 4301 1 DATE EXISTING UST DISCOVERED: 430b i. FACILITY INFORMATION FACILITY ID#(Agency Use Only) _ l ` 9 1 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 434 I �t� ®I.A STAND-ALONE TANK M r(-�1 /V) ❑2.ONE A COMPARTMENTED UNIT. 4 Complete me page for each com anment in the unit. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 20000 1 IIL'TANKUSE AND CONTENTS TANK USE ® la.MOTOR VEHICLE FUELING ❑ 1b.MARINA FUELING ❑ le.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): 439a CONTENTS PETROLEUM: ® la.REGULAR UNLEADED ❑ lc.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 440a NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(Specify): 4406 W. 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 LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 444a SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 14'6.0 ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL FLOAT ® 3.FELL TUBE SHUT-OFF VALVE ❑ 4.TANK MEETS REQUmEMENl'S FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT./WASTEPIPING,CONSTRUCIrION PIPING CONSTRUCTION ❑1.SINGLE-WALLED ®2.DOUBLE-WALLED ❑99.OTHER SYSTEM TYPE ® L PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR§2636(.)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ ]0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464a SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGIDPLASTIC 4646 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c FIPINGrrURBINE CONTAINMENT SUMP TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 90.NONE 4644 VI.VVENT,VAPOR RECOVERY(VR)AND RISER I FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464c 464el VENT SECONDARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ 10.RIGID PLASTIC 90.NONE ❑ 99,OTHER(Specify) 464f 464fi VR PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE 99.OTHER(Specify) 4648 464 I VR SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGIDPLASTIC 0 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL ❑ 2.DOUBLE WALL t9 90.NONE 4641. RISER PRIMARY CONTAINMENT ® 1.STEEL ❑ 4.FIBERGLASS 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 4691 464'1 RISER SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET ® 3.STRIKER PLATEBOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 451- VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ® 1.SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 4691 CONSTRUCTION MATERIAL ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10,RIGIDPLASTIC ❑ 99.OTHER(Specify) 4696-c VIUR CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ® 6.ISOLATION 449• 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 compliance with legal requirements. 470. APPLICANT DATE APP ANT N (prmt) 471' APPLICANT TITLE 472. Joey Cupp Environment Management UPCF UST-B-1/12 Rev.(12/2007)