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�a ts� 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,If.fll,IV,and IX below) 430 ❑ 1.NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE S.UST REMOVAL DATE.UST PERMANENTLY CLOSED: 4308 1 DATE EXISTING UST DISCOVERED: 4j61 1. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I 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 ,. T.T. Tz>,NK'I)ESCRIl'TION ` TANK ID# tr//�'� 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 �4 Ds I V v V ®i.AST INACOMPAT ME NK 4-Regular (J 1 � �C []2.ONE M A COMPARTMENTED UNIT, C000klo am PACW BO:smt in the-h.. DATE UST SYSTEM INSTALLED 475 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 20000 1 III.TANK USE AND CONTENTS "TANK USE ® In.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ lo.AVIATION FURLING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(IoJwvs Used 011) ❑ 5.EMERGENCY GENERATOR FUEL IHsc 52s2a1.5(c)1 ❑ 6.OTHER GENERATOR FUEL ❑ 95,UNKNOWN ❑ 99.OTHER(Specify): 439s CONTENTS PETROLEUM: ® 1 a.REGULAR UNLEADED ❑ I e.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JEI FUEL ❑ 6.AVIATION GAS ❑ 8.PETROLEUM BLEND FUEL, ❑ 9,OTHER PETROLEUM S i5:); 4401 NON-PFTROI,F.UM' 7.USED 011. Q 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM(S if : 4406 IV. TANK CONSTRUCTION TYPE OF TANK ❑ I.SINGLE WALL 02,I)OUBLF WALL ❑ 95.UNKNOWN 443 PRIMARY CONTAINMENT ❑ 1.STEEL 0 3.FIBERGLASS 0 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (S tecif : 444a SECONDARY CONTAINMHNr Q 1,STEEL 3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER 7,JACKETED 445 ❑ 90.NONE ❑ 9S.WNKNOWN 99.OTHER S it ase OVER1�1l.L PRF,VF.NTTON 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS RFQUIReaWTS FOR EXEMPTION FROM OVERFILL PREVFN71ON EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION.:. PIPING CONSTRUCTION ❑1.SINGLE-WALLED Ia 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE 0 1.PRESSURE ❑2,GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION III CCR$1636(4(3)1 459 PRIMARY CONTAINMENT 1.STEEL Xj.FIBERGLASS 8.FLI=.XIBLF ❑ I0.RIGID PLASTIC 464 Q 90.NONE ❑ 95.UNKNOWN 99.OITWR(Spcci4644 SECONDARY CONTAINMENT fj 1.STEEL 4.FIBERGLASS 8,FLEXIBLE 0 10.RIGIDPLASTIC 464h ❑ 90.NONE ❑ 95.UNKNOWN9.OTHER(S ocif); 46k P[PINGIFURBINE CONTAINMENT SUMP TYPE 1,SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 464d VL VENT;VAPOR RECOVERY(VR)AND RISER%FILL PIPE PIPINGCONSTRUCTION VENT PRIMARY CONTAINMENT 1,STEEL 10 4.FIBERGLASS 0 10.RtGn)PLASTIC 0 90.NONE 0 99.OTHER(Sptoify) 4640 46411 VENT SECONDARY CONTAINME"' 1.STEEL 0 4.FIBERGLASS 10.RIGID PLASTIC 0 90.NONE 99.cri-R ER(Sptcify) 464f 464f1 VR PRIMARY CONTAINMENT 1.STEEL a 4.FIBERGLASS < 10.RIGID PLASTIC 0 90.NONE. 99.-OTHER(Specify)' 64S VR SECONDARY CONTAINMENT I.STEEL 0 4.FIBIIRGLASS 10.RIGID PLASTIC 90.NONE 99.OTHER(Specify) n6+1 4601 VENT PIPING TRANSITION SUMP TYPE; 0 1.SINGLE WALL 2.DOUBLE.WALL M 90.NONE 464i, RISER PRIMARY CONTAINMENT P9 I.STEEL U 4.FIBERGLASS 10,RIGID PLASTIC ❑ 90.NONE LJ 99,OTHER(Specify) 464J 464'1 RISER SE=CONDARY CONTAINMENT ❑ 1.STEEL a 4.FIBERGLASS 0 10.RIGID PLASTIC 90.NONE 0 99,OINL'R(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 0 1,SPILT.BUCKET 0 3,STRIKER PLATEIBOTTOM PROTECTOR 0 4-cowA(NMENT SUMP 451 s, VII.VNDERDISPrN9ER CONTAINIVIENt(UDC), CONSTRUCTION TYPE 0 1.SINGLE WALL ❑ 2,DOUBLE WALL ❑ 3,NO DISPENSERS Q 90,NONE 46% CONSTRUCTION MA"ITsRIAL ❑ I.STEEL 0 4.FIBERGLASS I0.RIGID PLASTIC ❑ 99.OTHER(S i 4696-c VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION Q 2.SACRIFICIAL ANODF..(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 b,Tk1brate, and in full tom IiRnce with lepl requirements. APPLIC DATE ��-: 470. PL] AM (print) 471' APPLICANT TITLE a 472' Jo Cupp Environment Management UPCF UST-B-1/12 Rev.(12/2007)