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IFIED IIROGVNI CONSOLIDATED FORA � � ` C7� TANK: TA0133204 PR#: PR0231332 UNDERGROUND STORAGE TANKS - TANK E I t/1 FAC#: FA0003961 v� a( U? I (two pages per tank) A TYPE OF ACTION ❑ I NEW SITE PERMIT ❑ 4 AMENDED PERMITPage 2 of9 ❑ 5 CHANGE OF INFORMATION ❑ 6 TEMPORARY SITE CLOSURE (Check only item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Sped£,reason-for local me only) (Specify mason-for local use only) ❑8 TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Busincss As) FACILITY ID: PR#: LODI MUNI SERVICE CENTER FA0003961 PR0231332 LOCATION WITHIN SITE(optional) 1331 S HAM Ln,LODI 431 PHONE 1.TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TA\KID# Tank#: 4 yy, TANK MANUF , COMPARTMENTALIZED TANK ❑ Yes ❑ No 434 I TA0133204 PERKI If"Yes".complete one page for each compartment. DATE INSTALLED(YEAR/MO) 435 TANK CAPACI Y IN G NS ,36 NUMBER OF COMPARTMENTS 437 10,000 ADDITIONAL DESCRIPTION(For local mconly) 433 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ® 1.MOTOR VEHICLE FUEL ® la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If marked complete petroleum Type) ❑ Ib.PREMIUM UNLEADED ❑ 3.DIESEL ❑ 6.AVIATION FUEL ❑ 2.NON-FUEL PETROLEUM ❑ Ic.MIDGRADE UNLEADED ❑ 4.GASOHOL ❑ 99.OTHER ❑ 3.CHEMICAL PRODUCT COMMON NAME(from Hazardous Materials Imenton page) 441 CAS#(from Hazardous Materials Imrntory page) 44' ❑4.HAZARDOUS WASTE (I«ludcs Used Oil) ❑ 95.UNKNOWN Ill.TANK CONSTRUCTION' TYPE OF TANK ❑ 1.SINGLE WALL ❑ 3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM 443 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ® 2.DOUBLE WALL ❑ 4.SINGLE WALL IN VAULT 7 99.OTHER TANK MATERIAL-primary tank ® 1.BARE STEEL ❑ FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 444 (Check one item only) ❑ 2.STAINLESS STEEL ❑ STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/100%METHANOL REINFORCED PLASTIC(FRP) ❑ 99.OTHER 'TANK MATERIAL-secondary tank 1.BARE STEEL [-] 3.FIBERGLASS)PLASTIC E] 5.CONCRETE [-] 95.UNKNOWN 445 t heck one item only) ❑ 2.STAINLESS STEEL ❑ 4.STEEL CLAD W-FIBERGLASS ❑ 8.FRP COMPTIBLE W/1001%METHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ 1.RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED 447 OR COATING (Check one item only) ❑ 2 ALKYD LINING ❑ 4 PHENOLIC LINING 6 LNLINED E] 99.OTHER (For local use only) /^ THER CORROSION ; 1"s ANUFACTURING CATHODIC ❑ 3 FIBERGLASS REINFORCED PLASTIC p 95 UNKNOWN 443 DATE INSTALLED 449 ROTECTION IF APPLICABLE OTECTION heck one item only) E]4IMPRESSED CURRENT ❑ 99 OTHER �SACRIFICIAL ANODE (For local use only) SPILL AND OVERFILL YEAR INSTALLE450 TYPE tI«al use only) 431 0%ERFILL PROTECTION EQUIPMENT:YEAR INSTALLED 452 (Check all that apply) ❑ I SPILL CONTAINMENT ❑ I ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2 DROP TUBE ❑ 2 BALL ❑ 4 EXEMPT ❑ 3 STRIKER PLATE FLOAT IV.TAN K LEA K DETECTION(.4 description of the monitonng pro�wm shill be submitted to the local agency) F SINGLE WALL TANK(Check all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 4i4 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) 'Checkoneitemonly) ❑ 2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ 1 VISUAL(SINGLE WALL IN VAULT ONLY) ❑ 3 CONTINUOUS ATG ❑ 7 GROUNDWATER 2 CONTINUOUS INTERSTITIAL MONITORING ❑ 4 STATISTICAL INVENTORY RECONCILIATION ❑ 8 TANK TESTING ❑3 MANUAL MONITORING (SIR)BIENNIAL TANK TESTING ❑ 99 OTHER V.TANK CLOSURE INFOWNIATION/PERNtANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 7STIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL'! 457 El Yes E] No UPCF(12/99 revised)