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l <br /> UNIFIED PROGRAM CONSOIADATE D FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION(one form per UST) <br /> sannnnans PE OF ACTION (Chick one Ilam only. For un UST perm n nl closure m removal.eompltle only this x tiAm and Scctioms I,IL,HL IV,awl IX balm%l +"0 <br /> foiI.NEPA'PERMIT ® 3.RENF.WALPERMtT ❑ S.CHANGE OF INFORMATION <br /> l b.TEMPORARYUSTCLOSCIRF. Lj 7.UST PERMANENT CLOSURE ONS1TH R.USTREMOVAL <br /> ' DATE UST PERh1ANIsN'FLY CLOSED. <br /> iJt° 1 DAT 'EXISTING LIST DISCOVERED. 4:w <br /> L FACILITY INFORMATION <br /> FACILITY ED R(Agerny Use Onfj) - t <br /> BUSINESS NAME(Same as FACILITY NAML'or DBA-Doing Business As) ) <br /> EAST HARNEY ARCO <br /> BUSINESS$111;ADDRESS I°) C'1 I Y Im <br /> LODI <br /> 255 E.HARNEY LANE <br /> ll.TANK DESCRIPTION <br /> TANK IDR as TANK MANUFACTURER 4)) TANKCGSTIGURATION.THISTANKIS +1+ <br /> []I ASTAND-AIONETANK <br /> M 2.ONE IN A COMPARI'MENIt l?l�N(T <br /> %SAXES C Ina�m fie ash ram+nrm1 m mr <br /> DATE IST SYSTEM INS I'AI.LI:D 4)' TANK CAPACITY INGALLONS a1A N ITEROFCOhIPARTMENI. NII IE UNIT m) <br /> THD 12,000 2 <br /> 111.TANK USE AND CONTENTS <br /> TANK(JSE Is.MOTOR VFHICLE FUELING ❑ lb MARINAFUELING q Fc.AVI QN NIi1.IR(: 41' <br /> ❑ 3.CHEh11CA1.PR(IOI!C1 STORAGE ❑ 4.HAZARDOGS WASTE(InduA(S Vw,P.h ❑ S.FM GENCY GENERATOR FUEL(115C 6252BI 4ol <br /> ❑ 6.OT111]RUESERAIOR FUEL ❑ 95.UNKNON%N ❑ 99.0 <br /> 9. HER(Smi ): as+ <br /> CONH,WTS, PETROLEUM: q In,RBOULARUNI FAIR1) ❑ ic.MIDGRADE UNLEADED N 1 - RFAIIVAI UNLEADED u' <br /> ❑ i.DIESEL ❑ 5.JET full ❑ .AVIATION GAS <br /> ❑ R.PETROLEUM BLEND Full. ❑ 9.mill PR IROL LUM (S i ) <br /> NON-PETROLEUM ❑ 7.0.130II. ❑ 10 LIHANOL / <br /> ❑ ll.OTIIERSON-PETROLEUNI(5 it) <br /> W. TANK CONSTRUCT] <br /> TYPEOFTARK ❑ I.SIN4 E WALL 2.11DUR1,I W'AIJ. ❑ 95.UNKNOWN �) <br /> PRIMARY CONTAINMENT ❑ L ST <br /> 3.FIBERGLASS 0 iNTERW(E. . .ADDI[ft u4 <br /> D 7.STEEL�INTFRNALI.DING ❑ 95 ut ., N ❑ 99.OTHER IS 'h9 uh <br /> SECONDARY CONTAmflrN'1' qI.STEEL 3.FIBERGLASS [3 J, RNn:R RMFSIHR.ANF.1.]S'ER ❑ 7.JACKETED ++` <br /> g90.NONE ❑ 95_UNKNOWN ❑99.(T11JL-(iiS.66)- 41)+ <br /> OVl'RFILL PREVFN'I ION E I AUDIBLE&VISUAl.ALARMS M 3 HALL FLOA.I N J.MI.TL'9F 51m,01'RVAPT a52 <br /> ❑ 4 TANK MEETS REOL IREMENTS FOR EXEMPTION.FROM m•PRFIl1 PR}:v LSf)ON LQUIPh1ENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPINGCONSTRUCnON ❑LSINGLE-WALLED 7.T>D lldr-WALLS ❑99.O1HER 40 <br /> SYSTEM TYPE L1'RESSCRE ❑ 2.GRAV'Rl' 3 (�ONVENTIONALSCCI'ION ❑4.SAFESUCTIO 1121CCRi2630.04 +3r <br /> PRIMARY CONTAINMENT ❑ 1 STFBiI- 4.FIBERGLASS ❑ S.FLEXIBLE, ID.R!(iiD 1'1.AS'DC +w <br /> [I W.SUNC ❑45.UNKNOWN ❑ 99 OTI II7NI'll cifjrl: 4w, <br /> SECONDAR}'CONTAINMIN-1 ❑ I.STEEL 0 4IlurRGLASS qP.FLEXIBLE ❑ In RIGID PLASTIC arch <br /> ❑ 90.NON ❑ vs UNANOW ❑ 99.OTHER S i t. +wc <br /> PIPINGIU RBINE CONTAINMENT SUMP TYPE. U.SINGLE AL1. 2.DOUBLE WALL C3 90 NONE aw4 <br /> VI.VENT,VAPOR RECOVERY( )AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY COSTAINMENL' ❑ I.STEFL N4,FI RGLASS U 10.KWIDPLASUC 90.NONE 99.OTHFR(Specih) ro+e <br /> 4wel <br /> VENT SECONDARY COSTA)NNIFNT LSTEEI. #. BERGLASS 13 10 RIGID PLA.SIIC 90.NONE 13 99.OTHER(Stwif,I serf <br /> +wn <br /> A'R PKIMARY CONTAINMFNT U LSTEEL .FIBERGLASS E3 10 RIGID VILASMI If A).NONE 99.OTAFR(S( IMI •RAS <br /> VR SECONDARY CON TAI NStLN T ❑ I.ST1:F.1. 4 FIHEROLASS ❑ 10 RIGIDPI.ASTIC 90.NONE: LJ 99.OTHER(SlwiRI +s(A <br /> SwTI <br /> VENT PIPING TR.A&SITIONSt'_'IPPS ❑ I.SINGLE 4AL1, 2.DOUBLEWALL [1 90 NONE <br /> RISER PRIMARY CONTAINMENT u LSTEEL 4.FIBERGLASS U OLRICAVFL.ASTIC ❑ ".NONE U 9 OT"TR(Sp .f]l �1 <br /> )n(I <br /> RtSFRSr(T)NDARYCONTAINMENT I.STE 4.FIBERGI ASS L3 1D.RIUIO PLASTIC 90.NONE ❑ 99 OI'IWRIS[n6) +wr <br /> +wAl <br /> FILL COMPONE:ST5 INSTALLED I SP .1.BI'-KF'( i.STRIKER PLATBB(nT )N1 PRO 11-C'IOR 4.CONLIINMI!ST SUMP +<I+< <br /> 11.UNDER DISPENSER CONTAINMENT(UDC) <br /> CY)N9TRCCIION TYPE ❑ .SINGLEIYALI. 02.IH?UBLEWALL 0.NO DIMPI'.\SEAS ❑ 91?"NONE +!e+ <br /> CONSTRUCTION MIATTRLAL Ey 1.STEN 4.FIBERGLASS ❑ 11. RJGIDPLASTIC 99.01HFR(S ifD auvb-c <br /> Vlll. CORROSION PROTECTION 3 <br /> STEEL COMPOSE 'I PROTECT ION ❑ SACRIFICIALANODEl6) ❑ J 1X1PKESSEDCURRENT ❑ 6_ISOLA'LION <br /> IX, APPLICANT SIGNATURE : <br /> CERTIFI(.A <br /> " TION: 1 tertbfp that 1 UST s}stem is compalihle with the hanrdoas mahsmnrt stored and Ihal the information peoeidt is true,accurate, <br /> mod in full to blare nilh i at n ulremenq- ' <br /> DATE <br /> APPLICANT,SIGNATURE <br /> +7z <br /> APPI.IC:VNT NAME(print <br /> +P1 APPLICANTTIVVC <br /> Ce1J 11 KL aJ QHS <br /> L.� <br /> Rn'.(I2nm171 <br /> I:MF UNT-B-1t2J <br />