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a`t'JNIFIED PROGRAM CONSOLIDATED FLT.M 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 I,II,III,IV,and IX below) 430 0 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: 430° I DATE EXISTING UST DISCOVERED: 430E I. FACILITY INFORMATION FACILITY ID#(Agency Use Only) I BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) iLs 3 EAST HARNEY ARCO �I B255EE SI10J C HARNEY LANE ITY LODI la ADDRESS H.TANK DESCRIPTION TANK ID# 432 TANK MANUFACTURER 433 TANK CONFIGURATION: THIS TANK IS 434 1 TA 052 0 538 ■1.A STAND-ALONE TANK XERXES [12.ONE INA COMPARTMENTED UNIT. C len me pule for each mm mtia the milt. DATE UST SYSTEM INSTALLED 435 TANK CAPACITY IN GALLONS 436 NUMBER OF COMPARTMENTS IN THE UNIT 437 N/A 25, 000 1 III.TANK USE AND CONTENTS TANK USE Is.MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439 ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE(Includes Usd oil ❑ 5.EMERGENCY GENERATOR FUEL DISC$25281.5(c)] ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43% CONTENTS PETROLEUM: la.REGULAR UNLEADED ❑ la MIDGRADE UNLEADED ❑ lb.PREMIUM UNLEADED 440 ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS ❑ R.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM (Specify): 4400 NON-PETROLEUM:❑ 7.USED OIL ❑ 10.ETHANOL ❑ 11.OTHER NON-PETROLEUM S xi : 44ub IV. TANK CONSTRUCTION TYPE OF TANK ❑ LS LE WALL N 2.DOUBLE WALL ❑ 95.UNKNOWN 443 PR04ARY CONTAINMENT ❑ 1.STEEL E 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 ❑ 7.STEEL+INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER (Specify): 4440 SECONDARY CONTAINMENT ❑ 1.STEEL N 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ❑ 7.JACKETED 445 ❑ 90.NONE ❑ 95.UNKNOWN [199.OTHER(Si ): 4450 OVERFILL PREVENTION 1.AUDIBLE&VISUAL ALARMS 2.BALL FLOAT 3.FILL TUBE SHUT-OFF VALVE 452. ❑ 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION ❑I.SINGLE-WALLED 0 2.DOUBLE-WALLED ❑99.OTHER 460 SYSTEM TYPE I.PRESSURE ❑ 2.GRAVITY ❑ 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION[23 CCR 12636(a)(3)] 458 PRIMARY CONTAINMENT ❑ 1.STEEL 0 4.FIBERGLASS ❑ R.FLEXIBLE ❑ I0.RIGID PLASTIC 464 ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 0640 SECONDARY CONTAINMENT ❑ L STEEL 0 4.FIBERGLASS ❑ R.FLEXIBLE ❑ 10.RIGID PLASTIC abw ❑ 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): a6ac PIPING/TURBINE CONTAINMENT SOME TYPE ❑ 1.SINGLE WALL 0 2.DOUBLE WALL ❑ 90.NONE 464d VI.VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99,OTHER(Specify) 464e 464e1 VENT SECONDARY CONTAINMENT ❑ I.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 461r 4641 VR PRIMARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464g 464 I VR SECONDARY CONTAINMENT ❑ L STEEL 4.FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464h 464h1 VENT PIPING TRANSITION SUMP TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 90.NONE 4641 RISER PRIMARY CONTAINMENT 1.STEEL 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464j 4 jl RISER SECONDARY CONTAINMENT ❑ L STEEL E3 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify) 464k 464k1 FILL COMPONENTS INSTALLED 1.SPILL BUCKET E 3.STRIKER PLATE/BOTTOM PROTECTOR 0 4.CONTAINMENT SUMP 451a< VII.UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE ❑ 1.SINGLE WALL 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.N 464a CONSTRUCTION MATERIAL ❑ L STEEL 0 4.FIBERGLASS [1l0.RIGID PLASTIC ❑ 99.OTHER(Specify) _ 4696K VIII. CORROSION PROTECTION STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODE(S) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION IX. APPLICANT SIGNATURE IN CERTIFICATION: I certify that this UST system is compatible with the hazardous substance stored and that the information provided herq1jigrue,accurate, and in full compliance with legal requirements. APPLICANT SIGNATURE DATE470. 2/25/13 APPLICANT NAME(print) 471. APPLICANT TITLE Design Engineer 472 Jonathan Ramos UPCF UST-B-I/2 t( � Rev.(12/2007)