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o. <br /> kt, <br /> UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per US')) <br /> TYPE OF ACTION (Check one item only. For an UST permanent closure or removal;complete only this section and Sections 1,IT,Ill,IV,and IX below) 420 <br /> ❑ L NEW PERMIT ® 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 8.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED; 4304 I DATE EXISTING UST DISCOVERED: 430b <br /> I. FACILITY INFORMATION <br /> FACILITY]D#(Agency Use On b,) _ FT I <br /> BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business A.4) 3 <br /> Flying J Travel Plaza-#617 <br /> 13USINESS SITE ADDRESS 103 CITY jp4 <br /> 15237 N.Thomton Rd Lodi <br /> II.TANK DESCRIPTION <br /> TANK ID# d12 TANK MANUFACI'URER 433 TANK CONFIGURATION: THIS TANK IS 434 <br /> �A OS' I ��Q ®1,A STAND-ALONE TANK <br /> 5-Premium U Yj � rZrf <br /> �C ❑2.ONE M A COMPARTMENTED UNrr.. <br /> Complete one pose for each com arimont in the unit.. <br /> DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 426 NUMBER OF COMPARTMENTS IN THE UNIT 437 <br /> 12000 I <br /> III.TANK USE AND CONTENTS <br /> TANK USF. ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ 1c,AVIATION FUELING 439 <br /> ❑ 3.CHEMICAL PRODUCT STORAGE. ❑ 4.HAZARDOUS WASTE(I.Iud.Wed Oil) ❑ 5.EMERGENCY GENERATOR FUEL IHSC¢25781 5(c)) <br /> [:] 6.OTHER GENERATOR FUEL ❑ 95,UNKNOWN _ 99.OTHER <br /> 4396 <br /> CONTENTS PETROLEUM; ❑ l a.REGULAR UNLEADED ❑ 1 e.M DGRADE UNLEADED ® 1 ,PREMIUM UNLEADED 440 <br /> [13.DIESEL [35.JET FUEL .AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL .❑ 9.OTHER PETROLEUM S i ; 440a <br /> NON-PETROLEUM;❑ 7.USED OIL ❑ 10.ETHANOL <br /> ❑ <br /> 11.OTHER NON-PETROLEUM(Spactifyy 440h <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK 1.SINGLE WALL 0 2.DOUBLE WALL 95.UNKNOWN 443 <br /> PRIMARY CONTAINMENT ❑ 1,STEEL ® 3.FIBERGLASS 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL 4 INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER it : 444a <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3.FIBERGLASS 6.EXTERIOR MEMBRANE LINER ($7,JACKETED 445 <br /> ❑ 90.NONE ❑ 95,UNKNOWN 99.OTHER IS iT'; 4454 <br /> OVI:RFILl.PREVENTION l9 1.AUDIBLE&VISUAL ALARMS ❑ Z.BALI,FLOAT' 3.F7LLTUBE SHUT-OFF VALVE 451 <br /> ❑ 4,TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT I WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑L SINGLE-WALLED 0 2.DOUBLE.-WALLED ❑99.OTHER 466 <br /> SYSTEM TYPE 1.PRESSURE I GRAVITY P 3.CONVENTIONAL.SUCTION ❑ 4.SAFE SUCTION 3 CCR-j2636ta)0)1 458 <br /> PRIMARY CONTAINMENT 1.STEEL. 4.FIBERGLASS 8.FLF,XIBLE ❑ 10,RIGID PLASTIC 464 <br /> ❑ 90.NONE ❑ 95,UNKNOWN 99,OT'HBR(5 iry): <br />