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UNIFIED PROGRAM CONSOLIDATED FORM <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-TANK INFORMATION (One form per UST) <br /> TYPE OF-ACTION (Check one item only. For a L'S7'closure or removal,complete only this section and Sections 1,11,111.IV,and IX6elaw) 450. <br /> ❑ 1.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 LIST PERMANENTLY CLOSED: 4304 DATE EXISTING UST DISCOVERED: 430h <br /> I. FACILITY INFORMATION <br /> FACILITY ID h(Agency Use Only) <br /> BUSINESS NAME(Same as Facility Name or DBA-Doing Business As) 3 <br /> USA/Tesoro 68154 <br /> BUSINESS SILT ADDRESS 105, 1 CITY 104. <br /> 2500 W. Lodi Ave. Lodi <br /> II. TANK DESCRIPTION <br /> TAN IDN 432 TANK MANUFACTURER455. TANK CONFIGURATION:THIS TANK IS 454 <br /> .J Modern Welding ® 1..4 STAND-ALONE TANK Cnmpl...a M.fm..1, <br /> ❑ 2.ONEINA COMPARTMENTED UNIT cwnpuMenl in ax unit. <br /> DATE UST SYSTEM INSTALLF, a35 TANK CAPACITY IN GALLONS 436, NUMBER OF COMPARTMENTS IN THE UNIT uz <br /> Unknown Ib q 12,000 1 1 <br /> III. TANK USE AND CONTENTS <br /> TANK USE ® Is.MOTOR VEHICLE FUELING ❑ Ib MARINA FUELING 0 Ic.,,VIATION FUELING 439. <br /> ❑ 3.CHEMICAL PRODUCT STORAGE ❑ 4.HAZARDOUS WASTE arcmd.s UsW Oil) ❑ 5.E,IERGENCY GENERATOR FUEL(RSC§23281.$(.)1 <br /> ❑ 6.OTHER GENERATOR FUEL ❑ 95.UNKNOWN ❑ 99.OTHER(Specify): 43%, <br /> CONTENTS PETROLEUM: ® Ia REGULAR UNLEADED 13 I<.MIDGRADE UNLEADED ❑ Ib.PREMIUM UNLEADED 440. <br /> ❑ 3.DIESEL ❑ 5.JET FUEL ❑ 6.AVIATION GAS <br /> ❑ 8_PETROLEUM BLEND FUEL ❑ 9.OTHER PETROLEUM(Spec�y 440•. <br /> ....__._-_.___.-__ _ - ...__.-_ ..__....- _._..__.._ <br /> NON-PETROLEUM:�] 7.USED OIL ❑ 10.ETHANOL <br /> ❑ 11.OTHER NON-PETROLEUM(Specify): 44W. <br /> IV. TANK CONSTRUCTION <br /> TYPE OFIdTANK _ ❑ !.SINGLE WALL ® 2.DOUBLE WALL ❑ 95.UNKNOWN 443. <br /> PRARY CONTAINMENT ® 1.STEEL ❑ 3.FIBERGLASS ❑ 6.INTERNAL BLADDER 444 <br /> ❑ 7.STEEL+INTERNAL LINING ____ _ ❑ 95.UNKNOWN ❑ 99 OTHEII(Specifyy 444x. <br /> SECONDARY CONTAINMENT ❑ I.STEEL ❑3.FIBERGLASS ❑ 6.EXTERIOR MEMBRANE LINER ® 7.JACKETED a5. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑99.OTHER(Specify): 44L. <br /> OVERFILLPREVENTION M I.AUDIBLE&VISUAI ALARMS ® 2 BALL FLOAT ❑ 3.FILL TL BE SHUT-OFF VALVE, 453 <br /> ❑ J.TANK MEETS REQUIREMENTS FOR EXEMPTION FROM OVERFILL PREVENT ON EQUIPMENT <br /> V. PRODUCT/WASTE PIPING CONSTRUCTION <br /> PIPING CONSTRUCTION ❑ 1.SINGLE WALL ® 2.DOUBLE WALL ❑ 99.OTHER 466 <br /> SYSTEMTYPE ® 1,PRESSURE ❑ ? GRAVITY ❑ 3.CON VENTIONAL S UCTION I] 4.SARI SUCTION[D CCR§U364)(3)] 439. <br /> PRIMARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ® 8.FLEXIBLE ❑ I0.RIGID PLASTIC 464. <br /> ❑ 90.NONE ❑ 95.UNKNOWN ❑ ".OTHER(Specify) 464•. <br /> SECONDARY CONTAINMENT ❑ L STEEL ❑ 4 FIBERGLASS ® 8.FLEXIBLE ❑ 10.RIGID PLASTIC -464h. <br /> Cl 90.NONE ❑ 95.UNKNOWN ❑ 99.OTHER(Specify). 4Wc <br /> _. ._. .__ _-_-__-__ f _____. _. <br /> PIPING?URSINE CONTAINMENT SUMP TYPE Ig. I sINGLe WAIL ❑ ?.DOUBLE WALL NONE 464a. <br /> VI. VENT,VAPOR RECOVERY(VR)AND RISER/FILL PIPE PIPING CONSTRUCTION <br /> VENT PRIMARY CONTAINMENT ❑ 1.STEEL ® 4.FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.MEl 99 <br /> ONY .OTHER(Specify): 464e <br /> __._.. 44M <br /> VENT SECONDARY CONTAINMENT ❑ I.STEEL ❑ 4.FIBERGLASS ❑ 10.RIGID PLA ®AS 9o.NONI I ❑ 99 OTHER(Specify): <br /> R P4yB, <br /> - -P-RIMARY----R-Y-.__CONTAINM-EN _._ <br /> VT ❑ 1.STEEL ® J 1 FIBERGLASS ❑ 10.RIGIDPLASTIC ❑ 90 NOMI! ❑ 99 OTHER(Specify): <br /> VR SECONDARY CONTAINMENT ❑ 1 STEEL ❑ 4.FIBERGLASS ❑ In RIGIDPLASTIC ® 90.NONE: O 99.OTHER(Speciry): 4Wh. <br /> 464hl <br /> VENT PIPING TRANSITION SUMP TYPE ❑ I.SINGLE WALL ❑ 2.DOUBLE WALL ® 90.NONE: <br /> RISER PRIMARY CONTAINMENT ® 1 STEEL El FIBERGLASS ❑ 10.RIGID PLASTIC ❑ 90.NONE ❑ 99.OTHER(Spent') " <br /> 464L... <br /> RISER SECONDARY CONTAINMENT ❑ I.STEEL 9 J FIBERGLASS ❑ 10.RIGID PLASTIC ® 90.NONE ❑ W.OTHER(Specify): 56ki_ <br /> FILL COMPONENTSNTS INSTALLED ® I SPILL BUCKET ® i STRIKER PLATFJBO'ITObt PROTECTOR ® J.CONTAINMENTTS SUMP JSlec. <br /> VII. UNDER DISPENSER CONTAINMENT(UDC) <br /> CONSTRUCTION TYPE _ ® 1.SINGLE WALL [1-2.DOUBLE WALL ❑ 3.NO DISPENSERS ❑ 90.NONE coo <br /> _.MATE EEL - RIGIDPLASTIC _.... <br /> CONSTRUCTION MATERIAL ❑ I STEEL ❑ J FIBERGLASS ® ID RIGID PLASTIC ❑ 99.OTHER(Specify) <br /> VIII. CORROSION PROTECTION <br /> STEEL COMPONENT PROTECTION ❑ 2.SACRIFICIAL ANODES) ❑ 4.IMPRESSED CURRENT ❑ 6.ISOLATION <br /> IX. APPLICANT SIGNATURE <br /> CERTIFICATION: 1 certify that this UST system is compatible with the hazardous substance stored and that the information provided herein is t <br /> accura and in full compliance with le2al r< uirements. <br /> APPLICANT SIGNATURE.111 <br /> . DATE 8/3/2009 'a <br /> APPLICANT NAME(prinp Sandy dWards 671' APPLICANTTITLE Environmental Compliance 4 <br /> UPCF UST-B Rev.(1212007)-1/2 www.unidoes.org <br />