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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUNDSTORAGETANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF ACTION (Check one item only. For a UST closure or removat complete only this section and Sections 111.111.IV.and fX below) 430. <br /> ❑ I.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: °104 DATE EXISTING UST DISCOVERED: °306 <br /> L FACILITY INFORMATION <br /> FACILITY ID N(Agency Use Only) 1 s L <br /> BUSINESS NAME(.Same as Facility Name or DBA-Doing Business As) 3_ <br /> USA/Tesoro 68154 <br /> BUSINESS SITE ADDRESS I01 CITY 1M_ <br /> 2500 W. Lodi Ave. Lodi <br /> II. TANK DESCRIPTION <br /> TANK It 432 TANK MANUFACTURER 433 TANK CONFIGURATION:THIS TANK IS 434 <br /> b a'TAo506�,os Modern Welding ❑ 1 ASTAND-ALONE TANK Complo. pgb+ff°o+r.h <br /> ® 2.ONE IN A COMPARTMENTED UNIT --P--- <br /> DATE <br /> -P--DATE UST SYSTEM INSTALLED Jas TANK CAPACITY IN GALLONS 436, NUMBER OF COMPARTMENTS M THE UNIT 437 <br /> Unknown 6,000 2 <br /> III. TANK USE AND CONTENTS <br /> TANK USE ® le MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING ❑ Ic.AVIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.14AZARDOUSWASTEilncw4..U.moO) O 5.EMERGENCY GENERATOR FUEL HLSC 43528.5(.)) <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify)r 419m <br /> CONTENTS PETROLEUM ❑ Ia.REGULAR UNLEADED ❑ Ic.MNGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440, <br /> ® 3.DIESEL ❑ 5.JET FUEL Cl 6.AVIATION GAS <br /> ❑ B.PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Specify): 4404 <br /> _...._._.__. _ - . ___.._. ....____ _-.. _ _.__._._.... <br /> NON-PETROLEUM [3 ].USEDOIL ❑ IO.ETH 4NOL <br /> ❑ 11 OT HER NON-PETROLEUM(S i ): 4406. <br /> IV. TANK CONSTRUCTION <br /> TYPE OF TANK_ _ _ <br /> ❑ I.SINGLE WALL ® 2.DOLIBLE WALL ❑ 95.UNKNOWN 443_ <br /> PRIMARYCOMAINMENT ® 1.STEEL ❑ 3 FIBERGLASS ❑ 6.INTERNALBLADDtR 444 <br /> Cl ].STEEL.INTERNAL LINING ❑ 95.UNKNOWN ❑ 99.OTHER(Specita). <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑3.FIBERGLASS [36.EXTERIOR MEMBRANE LINER ® 7.JACKETED 413. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify). M54 <br /> OVERFILL PRL VENTION ® 1.AUDIBLE&VISUAL ALARMS ® 2.BALL FLOAT ❑ I FILL TUBE SHUT-OFF VALVE 452 <br /> ❑ 4.TANK MEETS REOUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENTION F.OII IPMFNT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ I.SINGLE WALL ® 2.DOUBLE WALL _ ❑ W.OTHER 440 <br /> SYSTEM TYPE ® LPRESSURE _ .[1_?.GRAVITY Q3.CONVENTIONA_LSu nON ❑ ISAFE.SCCTIO\I Iccag26I6(q2/) 458. <br /> PRIMARY CONTAINMENT ❑ I.STEEL C3 d.FIBERGLASS ® 8.FLEXIBLE ❑ IU.ItIG1U PLASTIC 464. <br /> 0 90.NONE _i 0 95.UNKNOWN _ ❑ 99.OTHER(S afy): 464• <br /> SECONDARY CONTAINMENT ❑ 1.STEEL ❑ 4.FIBERGLASS ® S.FLEXIBLE ❑ 10.RIGID PLASTIC 4646 <br /> ❑ 90.NONE [195.UNKNOWN ❑ 99.OTHER(Specify): 464. <br /> PIPING/TURBINE CONTAINMENT SUMP TYPE I SINGLE WALL ❑ '-.IJOLBLI W\LI. ® 90.NONE JW4 <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID Pt.AS ITC ❑ 90.NONE ❑ 99.OTHER(Specify): 464¢ <br /> VENT SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4 FIBERGLASS ❑ IO.RIGID PLASTIC ® 90 NONE ❑ 99 OTHER(Specily): °61f <br /> --------...__. .....--- ...-----......... _..-----. ..._._..__ 0401 <br /> VRPRIMARY CONTAINMENT ❑ I.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify). °60g <br /> VR SECONDARY CONTAINMENT ❑ I.S TEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ 99.OTHER(Specify): 4"M1' <br /> VENT PIPING TRANSITION SUMP I'YPE: ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE 46°` <br /> RISER PRIMARY CONTAINMENT ® L STEEL ❑ 1 FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Specify): 464 i' <br /> __.._ _ .__-_ .__- .__.. 463k". <br /> RISER SECONDARY CONTAINMENT ❑ I STEEL _�+ FIBERGLASS ❑ 10.RIf ID PLASTIC ® 90 NONE ❑ 99 OTHER(Specify): 46`11,(__ <br /> FILL COMPONENTS INSTALLED ® I.SPILL BUCKET' ® 3.S"FRIKER PLATEIBOTTOM PROTECTOR ® 4.CONTAINMENT SUMP 411mw <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE ® L SINGLE WALL ❑ 2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE 404 <br /> CONSTRUCTION MAI'ER IAL ❑ 1 S'fEEL ❑ 4.FIBERGLASS ® 10 RIGIDPLASTIC ❑ 99.OTHER(Specify) n696' <br /> VIII. CORROSION PROTECTION Cza <br /> STEEL COMPONENT PROTECTION ❑ 2 SACRIFICIAL ANODES ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION <br /> IX. APPLICANT SIGNATURE " <br /> x. <br /> CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is <br /> accurate,mud in full com fiance with le ml requirements. <br /> APPLICANT SIGNATURE S DATE 8/3/2009 <br /> APPLICANT NAME(print) Sandy Ed ds APPLICANTTIrLE Environmental Compliance 47 <br /> 2 <br /> UPCF UST-B Rev.(12/2007)-1/2 www.unidocs.org <br />