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_ UI <br /> L%W-VIED PROGRAM CONSOLIDATED FOI. <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removal,complete only this section and Sections 1,A 177,IV,and IX below) 410. <br /> ❑ 1.NEW PERMIT ❑ 3.RENEWAL PERMIT ❑ 5.CHANGE OF INFORMATION <br /> ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE ❑ S.UST REMOVAL <br /> DATE UST PERMANENTLY CLOSED: 430., 1 DATE EXISTING UST DISCOVEREPe G7;i <br /> I. FACILITY INFORMATION <br /> FACILITY ID#(Agency Use Only) „ <br /> _ _ �M. t <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) y <br /> FLAG CITY ARCO/SUBWAY MAY 212012 <br /> BUSINESS SITE ADDRESS 103. CITY tN- <br /> 14931 NORTH FLAG CITY BLVD. LODI, CA 95242 GAN J0Aau44CGJ'lN <br /> II. TANK DESCRIPTION HEALTH DEPA I TENT <br /> TANK ID# j 432. TANK MANUFACTURER 433. TANK CONFIGURATION:THIS TANK IS 414. <br /> TA0506224 ❑ L A STAND-ALONE TANK Complete one page for each <br /> ❑ 2.ONE IN A COMPARTMENTED UNIT compartment in the unit. <br /> DATE UST SYSTEM INSTALLED 435. TANK CAPACITYIN GALLONS n3s. NUMBER OF COMPARTMENTS IN THE UNIT 431, <br /> 4/1/1997 10,000 <br /> III. TANK USE AND CONTENTS <br /> TANK USE ® la.MOTOR VEHICLE FUELING ❑ lb.MARINA FUELING ❑ lc.AVIATION FUELING 439_ <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes used oil) ❑ 5.EMERGENCY GENERATOR FUEL LHSC§252815(c)] <br /> __[1 6 OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER S <br /> CONTENTS PETROLEUM: ❑ Ia.REGULAR UNLEADED "- "El ------_ E- --.EADE�-------------_.__.___-_._.._ <br /> ❑ Ic.MIDGRADE lJNLEADED ® Ib.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8.PETROLEUM BLEND FUEL [1 9.OTHER PETROLEUM(Specify)_ 440a. <br /> NON-PETROLEUM:E] 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM S ecif): 4406. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN443. <br /> RG <br /> PRIMARY CONTAINMENT ❑ I.STEEL ® 3.FIBELASS ❑ 6.INTERNAL BLADDER ______ __ <br /> __ ❑ 7.STEEL+INTERNAL LINING __El 95 UNKNOWN _0 99 OTHER(Specifyp: a44a. <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ®3 FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER <br /> ❑ 7.JACKETED 445. <br /> -._...,...__"-_❑ 90.NONE -❑ 95 UNKNOWN ..099_OTHER(Specify): 445a <br /> OVERFILL PREVENTION El 1.AUDIBLE&VISUAL ALARMS ❑ 2.BALL _ _ <br /> FLOAT ® 3.FILL TUBE SI-RIT-0FF VALVE 452. <br /> ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 460. <br /> SYSTEM TYPE ® 1;PRESSURE _O 2 GRAVITY- [1 3:CONVENTIONAL SUCTION ❑ 4 SAFE SUCTION L21 CCR g266(ax3)] 45s. <br /> PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ B.FLEXIBLE ❑ 10.RIGID PLASTIC 464_ <br /> ❑ 90.NONE _ ❑ 95.UNKNOWN ❑_99.OTHER(Sp_ecify): 464a. <br /> SECONDARY CONTAINMENT ❑ 1 STEEL ® 4.FIBERGLASS ❑ S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646_ <br /> ❑ 90.NONE _ __ ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 464c. <br /> PIPING/FURBLNE CONTAINMENT SUMP TYPE ❑ I SINGLE WALL ® 2.DOUBLE WALL ❑ 90.NONE 4644. <br /> VI. VENT, VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS El 10.RIGID PLASTIC [:190.NONE ❑ 99.OTHER(Specify): <br /> .........._ ..-.-____ __._.... .-.-.___-._ ............ .___-_ <br /> VENT SECONDARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 5 of <br /> _ ................___________.____ ...__.___ _.._-___-- ._--..__. __.. -----------------___.___-__---- -.__-.___ -_-----_-------..._ <br /> VR PRIMARY CONTAINMENT ❑ I STEEL ® 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑ 99.OTHER(Specify): 4464g, <br /> .................._.-__.--.._-_ ____-___._. .. ._.-.-._._ ______._ ..--- ._-_.__. ______.-. __-____- -............_ _._.-.._... <br /> VR SECONDARY CONTAINMENT ❑ 1 STEEL ® 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46hh' <br /> VENT PIPING TRANSITION SUMP TYPE I SINGLE WALL 13 <br /> 2.DOUBLE WALL ❑ 90.NONE <br /> _ ........... ._.-__ _..._ _. ...._ ....-.--O .... ._....... 1 .. <br /> RISER PRIMAR_Y CONTAINMENT El 1 STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90 NONE ❑_99.OTHER(Specify-).:___ 4aai, <br /> RISER SECONDARY CONTAINMENT 0 I STEEL ® 4 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 46441 _ <br /> FILL COMPONENTS INSTALLED ❑ 1 SPILL BUCKET ❑ 3.STRIKER PLAUMOTTOM PROTECTOR ❑ 4.CONTAINMENT SUMP 455a-o. <br /> VII. UNDER DISPENSER CONTAINMENT (UDC) I <br /> -CONSTRUCTION TYPE __ _ _® 1 SINGLE WALL 2.DOUBLE WALL ---------.......... ........... ._....-_-. .___.-.-...... <br /> CONSTRUCTION MATERIAL ❑ L STEEL ® 4.FIBERGLASS ❑ lo.RIGID PLASTIC ❑ 99.OTHER(Specify) ---- 4696.- <br /> 469c. <br /> VIIL CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION "a <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: I certify th thi system is compatible with the hazardous substance stored and that the iof r tion pr id herein is true, <br /> accurate n i I m liance with 1 al re uirements. <br /> APPLICANT SIGNATURE <br /> APPLICANT NAME(print) I HALLOIJM 411' APPLICANT TITLE OWNER 412_ <br /> UPCF UST-B Rev.(12/2007)-112 www.unidoes.org <br />