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Cot) Ar- UNIFIED PROGRAM CONSOLIDATED FORM UNDERGROUND STORAGE TANK OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) TYPE OF ACTION (Check mre item only For a UST closure or removal,complete only(his section and Sections 1,Il.111.1V,and LYbelow) 430 ❑ I.NEW PERMIT ❑ 3.RENEWAL PERMIT ® 5.CHANGE OF INFORMATION ❑ 6.TEMPORARY UST CLOSURE ❑ 7.UST PERMANENT CLOSURE ON SITE 0 S.UST REMOVAL DATE LIST PERMANENTLY CLOSED: 410. DATE EXISTING UST DISCOVERED: 4306 I. FACILITY INFORMATION C� FACILITY ID N(.Agency Use Only) BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 USA/Tesoro 68154 BUSINESS SITE ADDRESS 103 CITY 10d 2500 W. Lodi Ave. Lodi II. TANK DESCRIPTIO_ N TANK IDN A3 TANK MANUFACTURER i33 TANK CONFIGURATION:THIS TANK IS 414 #� )c AOSOU06 Modem Welding LASTAND-ALONETANK c9mpla.orepgr(o4T7 2.ONE IN A COMPARTMENTED UNIT c9mpenmem i.me unit DATE UST SYSTEM INSTALLED 415 TANK CAPACITY IN GALLONS 011 NUMBER OF COMPARTMENTS IN THE UNIT 4n Unknown 6,000 2 _ III. TANK USE AND CONTENTS TANK USE S Is,MOTOR VEHICLE FUELING ❑ Ib.MARINA FUELING D le.AVIATION FUELING 439. D 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE Omtud Wed 011) D 5.EMERGENCY GENERATOR FUEL IHsC§351a1$(c)) D b.OTHER GENERATOR FUEL D 95.UNKNOWN 439. CONTENTS PETROLEUM: D Is REGULAR UNLEADED D Ic MIDGRADE UNLEADED PREMIUM UNLEADE 44° $3.CIPSFI D 5.JET FC EL D 6.AV D 8.PETROLEUM BLEND FUEL. D 9.OTHER PE I'ROLFUM(Specify): a4M NON-PETROLEUM ❑ 7.USED OIL ❑ 10 ETHANOL D IL OTHER NON-PETROLEUM(Specify) 4406. IV. TANK CONSTRUCTION TYPE OF TANK D 1.SINGLE WALL S 2 DOUBLE WALL D 95.UNKNOWN i43 PRRv1ARY CONTAINMENT S I.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER w4. ❑ 7.STEEL+INTERNAL LINING____ ,._�_95,UNKNOWN.,,_ [199._OTHER City)* 444 . _ __._- _ ._ .....__.._. SECONDARY CONTAINMENT ❑ 1.STEEL D 3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER S 7.JACKETED M5. D 90,NONE D 95.UNKNOWN D 99.OTHER(Specify). 445.. _._.... _._... ...... ._ _.__. . ______..__ ___ OVERFILL PREVENTION ® I.AUDIBLE&VISUAL ALARMS S 2.BALL FLOAT ❑ 3.FILL TUBE SHUT-OFF VALVE 463. D 4.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL.PREVENTION EQUIPMENT V. PRODUCT/WASTE PIPING CONSTRUCTION PIPING CONSTRUCTION D 1.SINGLE WALL S 2.DOUBLE WALL D 99.OTHER i60 __.__ _.._ -_________ _ SYSTEM TYPE S 1.PRESSURE ❑ 2 GRAVITY D 3.CONVENTIONAL SUCTION ❑ 4.SAFE SUCTION 13 LCR gx636(a%])) 45a. PRIMARY COMAINMF:NT ❑ L STEEL ❑ 4 FIBERGLASS S S.FLEXIBLE ❑ 10 RIGID PLASTIC 464 D 90.NONE D 95.UNKNOWN D 99.OTHER(Specify): 464+ SECONDARY CONTAINMENT ❑ L STEEL ❑ d.FIBERGLASS S 8.FLEXIBLE ❑ 10.RIGID PLASTIC 46'6 D 90.NONE D 95.UNKNOWN D 99.OTHER(Sp=fyr 46U PIPING?URBINE CONTAINMENT SUMP TYPE ❑ I SINGLE WALL ❑ 2.DOUBLE WALL S W.BONE 4644 VI. VENT,VAPOR RECOVERY (VR)AND RISER/FILL PIPE PIPING CONSTRUCTION VENT PRIMARY CON'TAINMEN'T D I.STEEL S 4.FIBERGLASS D 10,RIGID PLASTIC D W.NONE D 99.OTHER(Speci y): 446 VENT SECONDARY CONTAINMENT D 1.STEEL D 4.FIBERGLASS D 10.RIGID PLASTIC S W.NONE D 99.OTHER(Specify): 464171 VR PRIMARY&R4TAINMEM D I.STEEL ® 4.FIBERGLASS D 10.RIGID PLASTIC D 90.NONE D 99.OTHER(Specify): 4648 461 1 VR SECONDARY CONTAINMENT D I.STEEL D d FIBERGLASS D 10.RIGID PEAS 1'IC S W.NONE D 99.OTHER(Specify): 4M4 ....__.__ .11. VENT PIPING TRANSITION SUMP TYPE D I.SINGLE WALL D 2.DOUBLE WALL S 90NONE RISER PRIMARY CONTAINMENT S L STEEL D 4 FIBERGLASS D 10,RIGID PLASTIC D W.NONE D 99.OTHER(Specify): RISER SE CONDARYCONTAINMENT D I STEEL D 4.FIBERGLASS D IO.RIGIDPLASTIC S W.NONE ❑ 99.OTHER(Specify} Oak; FILL COMPONENTS INSTALLED S L SPILL BUCKET S 3.STRIKER PLATEIBOTTOM PROTECTOR S 4 CONTAINMENT SUMP 451a� VII. UNDER DISPENSER CONTAINMENT(UDC) CONSTRUCTION TYPE S I.SINGLE WALL D 2 DOUBLE WALL D 3.NO DISPENSERS D 90.NONE CONSTRUCTION MATERIAL D 1 STEEL D 4.FIBERGLASS S 10 RIGID PLASTIC D 99 OTHER(Specify) 4 VIII. CORROSION PROTECTION STEEL_COMPONENT PROTECTION D 2.SACRIFICIAL ANODES) D 4.IMPRLS1,., . .'n_I D 6.ISOLATION , IX. APPLICANT SIGNATURE fir. CERTIFICATION: I certify that this UST system is compatible with the haurdous substance stored and that the information provided herein is t accurate,and in full comehapSe with 15gal re uiremeots. _ APPLICANT SIGNATURE S DATE g/3 f2009 APPLICANT NAME(print) Sandy Ed Ards 471' APPLICANTTITLE Environmental Compliance UPCF UST-B Rev.(1212007)-1/2 www.unidomorg