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IDS IFIED PROGRAM CONSOLIDATED FOR TANK: TA0133205 PR#: PR0231332 UNDERGROUND STORAGE TANKS - TAN i �f U� FAC#: FA0003961 a( D3 (two pages per tank) TYPE OF ACTIONPage 4 of 9 ❑ 1 NEW SITE PERMIT ❑ 4 AMIE\DED PERMIT ❑ 5 CHANGE OF INFORMATION ❑6 TEMPORARY SITE CLOSURE (Check only item only) ❑ 7 PERMANENTLY CLOSED ON SITE ❑ 3 RENEWAL PERMIT (Spedfyrcason-forlocalweonly) (Specifyresoo-forlocalweonly) ❑8TANK REMOVED 430 BUSINESS NAME(Same as FACILITY NAME or DBA-Doing Business As) FACILITY ID: PR#: LODI MUNI SERVICE CENTER 3 FA0003961 PR0231332 LOCATION WITHIN SITE(Optional) 1331 S HANI Ln,LODI 431 PHONE L TANK DESCRIPTION(A scaled plot plan with the location of the UST system including buildings and landmarks shall be submitted to the local agency.) TANK ID# Tank#: 5 431 TANK MANUFACTURER 433 COMPARTMENTALIZED TANK ❑ Yes ❑No 431 TA0133205 N J MCCUTCHEON If"Yes",complete one page for each compartment. DATE INSTALLED(YEARMO) 435 TANK CAPACITY NS J36 NUMBER OF COMPARTMENTS 437 2,000 ADDITIONAL DESCRIPTION(For local use only) L,1/ 433 II.TANK CONTENTS TANK USE 439 PETROLEUM TYPE 440 ❑ I.MOTOR VEHICLE FUEL ❑ la.REGULAR UNLEADED ❑ 2.LEADED ❑ 5.JET FUEL (If marked complete Petrolearn 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 HazardottsSletcnals Imrntory,page) 441 CAS#(from Hazardous Materials Inventory page) 442 ® 4.HAZARDOUS WASTE (Includes Used OO) VAS TE OIL ❑95.UNKNOWN III.TANK CONSTRUCTION TYPE OF TANK ❑ 1.SINGLE WALL ❑3.SINGLE WALL WITH ❑ 5.SINGLE WALL WITH INTERNAL BLADDER SYSTEM ++3 (Check one item only) EXTERIOR MEMBRANE LINER ❑ 95.UNKNOWN ® 2. OUBLE W ALL ❑4.SINGLE WALL IN VAULT ❑ 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 ANK MATERIAL 211.BARE STEEL ❑ 3.FIBERGLASS/PLASTIC ❑ 5.CONCRETE ❑ 95.UNKNOWN 445 Check one item only) ❑ 2.STAINLESS STEEL ❑ 4.STEEL CLAD W/FIBERGLASS ❑ 8.FRP COMPTIBLE W/10094M ETHANOL REINFORCED PLASTIC(FRP) ❑ 10.COATED STEEL ❑ 99.OTHER ❑ 5.CONCRETE TANK INTERIOR LINING ❑ L RUBBER LINED ❑ 3.EPDXY LINING ❑ 5.GLASS LINING ❑95.UNKNOWN 446 DATE INSTALLED OR COATING UNLINED only) ❑item 2 ALKYD LINING 4 PHENOLIC LINING 6 UNL ❑ 99.OTHER (Check one ❑ ® 1 For local use only) COTHER CORROSION ❑ I M UFACTURING CATHODIC 95 UNKNOWN 449 DATE INSTALLED 449 PROTECTION IF APPLICABLE P TECTION ❑ 3 FIBERGLASS REINFORCED PLASTIC ❑ � ❑4 IMPRESSED CURRENT ❑ 99 OTHER (Check one itcm only) 2 SACRIFICIAL ANODE (For local tug only) SPILL AND OVERFILL YEAR INSTALLE430 TYPE(local wconly) 451 OVERFILL PROTECTION EQUIPMENT:YEAR INSTALLED (Check all mat apply) ❑ I SPILL CONTAINMENT ❑ I ALARM ❑ 3 FILL TUBE SHUT OFF VAL` ❑ 2DROPTUBE ❑ 2BALL ❑ 4EXEMPT ❑ 3 STRIKER PLATE FLOAT IV.TANK LEAK DETECTION(A description of the monitoring program shall be submitted to the local agency) IF SINGLE WALL TANK tChcck all that apply) 453 IF DOUBLE WALL TANK OR TANK WITH BLADDER 411 ❑ 1 VISUAL(EXPOSED PORTION ONLY) ❑ 5 MANUAL TANK GAUGING(MTG) (Check one item only) ❑2 AUTOMATIC TANK GAUGING(ATG) ❑ 6 VADOSE ZONE ❑ I 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 INFORMATION/PERMANENT CLOSURE IN PLACE ESTIMATED DATE LAST USED(YR/MO/DAY) 455 ESTIMATED QUANTITY OF SUBSTANCE REMAINING 456 TANK FILLED WITH INERT MATERIAL? 457 ❑ Yes ❑ No UPCF(12/99 revised)